Staff Roster and Certification Information Provide information about each qualified staff member at the agency.
If clinicians and supervisors are not certified through the listed entity, please provide additional information about the qualifications of the trainer, the training and consultation received, and attach supporting documentation.
Note: These applications will be reviewed to determine if the necessary qualifications to receive the specialized EBP rate are met or to determine what additional steps are needed to qualify.
Name of Practitioner #1
First
Last
Employment status Certified by EMDR International Association (EMDRIA) Certification Program? (emdria.org) Upload Documentation of Certification from EMDR International Association (EMDRIA) Certification Program (emdria.org)
Completed an EMDRIA Approved Basic Training If yes, you will be asked to upload documentation in following question.
Upload Documentation of completion of all components of the EMDRIA Approved Basic Training
Is the trainer on the EMDRIA List of Qualified Trainers? Hidden
Have you completed the TF-CBT Web 2.0 online course? If yes, you will be asked to provide certificate in next question.
Hidden
Upload TF-CBT Web 2.0 certificate
Hidden
Have you completed a live 2-day (virtual or in-person) TF-CBT course? If yes, you will be asked to provide date, hours completed, and additional documentation in the following questions.
Hidden
Upload any supporting documentation about the Live TF-CBT curriculum
Description of EMDR training (hours, format content)
Hidden
Have you participated in a TF-CBT consultation group with a If participated with trainer or supervisor, you will be asked to provide additional information in the following questions.
Hidden
If it was a supervisor, were they working at the same agency as you at the time? Description of EMDR practicum (hours, format, dates)
Description of Consultation (hours, frequency / duration / dates, format of case consultation review, e.g. video, audio, case discussion)
Additional assessments completed to demonstrate competency in the model Including information about the number of cases completed, how many involved caregivers in treatment, and use of standardized measure.
Upload Supporting Documentation of the Trainer(s) Qualifications and Training
Additional Practitioners in this EBP? Name of Practitioner #2
First
Last
Employment status Certified by EMDR International Association (EMDRIA) Certification Program? (emdria.org) Upload Documentation of Certification from EMDR International Association (EMDRIA) Certification Program (emdria.org)
Completed an EMDRIA Approved Basic Training If yes, you will be asked to upload documentation in following question.
Upload Documentation of completion of all components of the EMDRIA Approved Basic Training
Hidden
Have you completed the TF-CBT Web 2.0 online course? If yes, you will be asked to provide certificate in next question.
Hidden
Upload TF-CBT Web 2.0 Certificate
Hidden
Have you completed a live 2-day (virtual or in-person) TF-CBT course? If yes, you will be asked to provide date, hours completed, and additional documentation in the following questions.
Hidden
Upload any supporting documentation about the Live TF-CBT curriculum
Is the trainer on the EMDRIA List of Qualified Trainers? Description of EMDR training (hours, format content)
Hidden
Have you participated in a TF-CBT consultation group with a If participated with trainer or supervisor, you will be asked to provide additional information in the following questions.
Hidden
If it was a supervisor, were they working at the same agency as you at the time? Description of EMDR practicum (hours, format, dates)
Description of Consultation (hours, frequency / duration / dates, format of case consultation review, e.g. video, audio, case discussion)
Additional assessments completed to demonstrate competency in the model Including information about the number of cases completed, how many involved caregivers in treatment, and use of standardized measure.
Upload Supporting Documentation of the Trainer(s) Qualifications and Training
Additional Practitioners in this EBP? Name of Practitioner #3
First
Last
Employment status Certified by EMDR International Association (EMDRIA) Certification Program? (emdria.org) Upload Documentation of Certification from EMDR International Association (EMDRIA) Certification Program (emdria.org)
Completed an EMDRIA Approved Basic Training If yes, you will be asked to upload documentation in following question.
Upload Documentation of completion of all components of the EMDRIA Approved Basic Training
Is trainer on the EMDRIA List of Qualified Trainers? Hidden
Have you completed a live 2-day (virtual or in-person) TF-CBT course? If yes, you will be asked to provide date, hours completed, and additional documentation in the following questions.
Hidden
Upload any supporting documentation about the Live TF-CBT curriculum
Description of EMDR training (hours, dates, format, content)
Hidden
Have you participated in a TF-CBT consultation group with a If participated with trainer or supervisor, you will be asked to provide additional information in the following questions.
Hidden
If it was a supervisor, were they working at the same agency as you at the time? Description of EMDR practicum (hours, format, dates)
Description of Consultation (hours, frequency / duration / dates, format of case consultation review, e.g. video, audio, case discussion)
Additional assessments completed to demonstrate competency in the model Including information about the number of cases completed, how many involved caregivers in treatment, and use of standardized measure.
Upload Supporting Documentation of the Trainer(s) Qualifications and Training
Additional Practitioners in this EBP? Name of Practitioner #4
First
Last
Employment status Certified by EMDR International Association (EMDRIA) Certification Program? (emdria.org) Upload Documentation of Certification from EMDR International Association (EMDRIA) Certification Program (emdria.org)
Completed an EMDRIA Approved Basic Training If yes, you will be asked to upload documentation in following question.
Upload Documentation of completion of all components of the EMDRIA Approved Basic Training
Is trainer on the EMDRIA List of Qualified Trainers? Hidden
Have you completed a live 2-day (virtual or in-person) TF-CBT course? If yes, you will be asked to provide date, hours completed, and additional documentation in the following questions.
Hidden
Upload any supporting documentation about the Live TF-CBT curriculum
Description of EMDR training (hours, dates, format, content)
Hidden
Have you participated in a TF-CBT consultation group with a If participated with trainer or supervisor, you will be asked to provide additional information in the following questions.
Hidden
If it was a supervisor, were they working at the same agency as you at the time? Description of EMDR practicum (hours, format, dates)
Description of Consultation (hours, frequency / duration / dates, format of case consultation review, e.g. video, audio, case discussion)
Additional assessments completed to demonstrate competency in the model Including information about the number of cases completed, how many involved caregivers in treatment, and use of standardized measure.
Upload Supporting Documentation of the Trainer(s) Qualifications and Training
Additional Practitioners in this EBP? Name of Practitioner #5
First
Last
Employment status Certified by EMDR International Association (EMDRIA) Certification Program? (emdria.org) Upload Documentation of Certification from EMDR International Association (EMDRIA) Certification Program (emdria.org)
Completed an EMDRIA Approved Basic Training If yes, you will be asked to upload documentation in following question.
Upload Documentation of completion of all components of the EMDRIA Approved Basic Training
Are they on the EMDRIA List of Qualified Trainers? Hidden
Have you completed a live 2-day (virtual or in-person) TF-CBT course? If yes, you will be asked to provide date, hours completed, and additional documentation in the following questions.
Hidden
Upload any supporting documentation about the Live TF-CBT curriculum
Description of EMDR training (hours, format content)
Description of EMDR practicum (hours, format, dates)
Hidden
Have you participated in a TF-CBT consultation group with a If participated with trainer or supervisor, you will be asked to provide additional information in the following questions.
Hidden
If it was a supervisor, were they working at the same agency as you at the time? Description of Consultation (hours, frequency / duration / dates, format of case consultation review, e.g. video, audio, case discussion)
Additional assessments completed to demonstrate competency in the model Including information about the number of cases completed, how many involved caregivers in treatment, and use of standardized measure.
Upload Supporting Documentation of the Trainer(s) Qualifications and Training
Additional Practitioners in this EBP? 
