Prolonged Exposure (PE) Rostering Application - Treatment Collaborative for Traumatized Youth

General Information

First Name*

Last Name*

Degree (ex. M.S., M.E.d)*

License (ex. LPC, LPCC)*

Personal Email Address*

Professional Email Address*

Personal Phone Number*

Agency Phone Number*

Agency Name*

Agency Address*

Agency City*

Agency State*

Agency ZIP Code*

Agency County*

Agency Type (ex. residential, inpatient, outpatient)*

Agency Website*

Have you participated in and completed a PE training workshop from a certified PE trainer?*

Date of training*

Trainer name*

Trainer organization*

Proof of PE workshop*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Have you participated in and completed consultation from a certified PE consultant as part of your PE training?*

Date of consultation*

Name of approved consultant*

Consultant organization*

Proof of PE consultation completion*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Are you a certified PE therapist?*

Proof of PE consultation completion*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.

Message (Optional)

Comments

This field is for validation purposes and should be left unchanged.