Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS) 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 SPARCS trainings hosted by certified SPARCS trainers(~4 days of training total)?*

Date of training*

Name of trainer*

Trainer organization*

SPARCS learning collaborative proof of completion*

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Have you participated in ongoing consultation calls as part of your SPARCS training?*

Date of calls*

Call trainer name*

Call trainer organization*

Proof of SPARCS consultation calls*

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

Message (Optional)

Name

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