DBT Interest Form

If you have received some training in DBT but do not currently meet the DBT qualification standards, or if have interest in trainings in DBT, please complete this DBT Interest Form. The information you provide will be used to guide NMSU Center for Innovation’s future trainings to support providers in achieving the DBT qualifications required for the DBT specific rate.

Step 1 of 2

50%

I. Agency Service Data

Agency Name(Required)

Agency address(Required)

Street Address Address Line 2 City State ZIP Code

Medicaid Enrollment ID

Primary County of Service(Required)

Does agency/provider serve additional counties?(Required)

Yes

Additional Counties Served(Required)

Type each county served, separate with comma.

Which populations does/will the DBT team serve?(Required)

Check all that apply

Adolescents

Adults

Does your agency currently work with/accept referrals for children in state custody (child welfare)?(Required)

Yes

Level of care or service where DBT is/will be delivered(Required)

Outpatient

School-based

Residential

Community-based

Other

Description of DBT Program(Required)

Check all that apply.

DBT Individual Therapy

DBT Skills Group

DBT Skills Coaching

DBT Consultation team for team therapists

Please describe level of care or service where DBT is delivered(Required)

Agency is current funded by/contracted with the following:(Required)

Select all that apply.

MCO- Blue Cross Blue Shield of New Mexico (Centennial Care)

MCO-Presbyterian Health Plan (Centennial Care)

MCO-Western Sky Community Care (Centennial Care)

NM Medicaid Fee for Service

Direct Contract with CYFD

Direct Contract with BHSD

Other

Other funding/contract(Required)

Point of Contact Name(Required)

First Last

Title(Required)

Phone(Required)

Email(Required)

II. Staff Information

List the practitioners at your agency who are interested in becoming qualified to deliver DBT with the Medicaid DBT specific rate

Name of Practitioner #1(Required)

First Last

Email(Required)

Current DBT Status(Required)

Visit DBT Linehan to learn more about certification.

Check all that apply.

No DBT training

Participated in DBT didactic training

Participated in DBT expert clinical consultation

Experience delivering DBT following the Linehan model (using the manual)

Anything else you would like to tell us about your training or experience with DBT?

Anything else you would like to tell us about your interest in DBT training?

Additional Practitioners interested in this EBP?(Required)

Yes

Name of Practitioner #2(Required)

First Last

Email(Required)

Current DBT Status(Required)

Visit DBT Linehan to learn more about certification.

Check all that apply.

No DBT training

Participated in DBT didactic training

Participated in DBT expert clinical consultation

Experience delivering DBT following the Linehan model (using the manual)

Anything else you would like to tell us about your training or experience with DBT?

Anything else you would like to tell us about your interest in DBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #3(Required)

First Last

Email(Required)

Current DBT Status(Required)

Visit DBT Linehan to learn more about certification.

Check all that apply.

No DBT training

Participated in DBT didactic training

Participated in DBT expert clinical consultation

Experience delivering DBT following the Linehan model (using the manual)

Anything else you would like to tell us about your training or experience with DBT?

Anything else you would like to tell us about your interest in DBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #4(Required)

First Last

Email(Required)

Current DBT Status(Required)

Visit DBT Linehan to learn more about certification.

Check all that apply.

No DBT training

Participated in DBT didactic training

Participated in DBT expert clinical consultation

Experience delivering DBT following the Linehan model (using the manual)

Anything else you would like to tell us about your training or experience with DBT?

Anything else you would like to tell us about your interest in DBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #5(Required)

First Last

Email(Required)

Current DBT Status(Required)

Visit DBT Linehan to learn more about certification.

Check all that apply.

No DBT training

Participated in DBT didactic training

Participated in DBT expert clinical consultation

Experience delivering DBT following the Linehan model (using the manual)

Anything else you would like to tell us about your training or experience with DBT?

Anything else you would like to tell us about your interest in DBT training?

Additional Practitioners in this EBP?

Yes

The limit for the number of practitioners per interest form has been met.

Please email [email protected] if EMDR team is greater than five.

I. Agency Service Data

II. Staff Information

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