Trauma Focused Cognitive Behavior Therapy (TF-CBT) EBP Provider Qualification Questionnaire

Step 1 of 2

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Name of person completing the application

First Last

Title

Phone

Agency Name

Solo Practitioner Name

First Last

Agency address

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in a secondary location other than the address provided above?

Yes

Additional address EBP is delivered

Street Address Address Line 2 City State ZIP Code

Primary County of Service

Does agency/provider serve additional counties?

Yes

Additional Counties Served

Type each county served, separate with comma.

Does agency/provider have experience serving youth in foster care?

Yes

Target Age of Population Served

Check all that apply

0-5

5-10

10-15

15-20

20-25

25+

Other

Target Age of Population Served

Level of care or service where TF-CBT is delivered

Outpatient

School-based

Residential

Community-based

Other

Describe other level of care or service where TF-CBT is delivered

List CYFD contracts currently held

Each contract can be listed separately. Press + to add new line.

List BHSD contracts currently held

Each contract can be listed separately. Press + to add new line.

Agency is contracted with the following MCOs:

Presbyterian

Western Sky Community Care

Blue Cross Blue Shield

Agency NPI

Medicaid Enrollment ID

Number of certified/endorsed practitioners?

The total number of certified in TF-CBT practitioners that are applying to be verified providers.

Max of 5 providers per application

Total capacity to serve target population?

The combined total capacity of all certified/endorsed TF-CBT providers that are applying to be a provider.

Ex. Five providers each have a capacity of 5 TF-CBT cases, total caseload capacity = 25

Name of executive at agency submitting application

First Last

Title

Phone

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

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program? (tfcbt.org)

Yes, Upload Documentation of Certification

Yes, Provide Listing on TF-CBT Certified Therapist page

Upload Documentation of Certification from Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org)

Drop files here or

Max. file size: 100 MB.

Link to your listing on tfcbt.org find a TF-CBT Certified Therapist page https://tfcbt.org/therapists/

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Provide the following information about the training experience for review.

Is the trainer TF-CBT approved?

(treatment developer or graduate of the TF-CBT Train-the-Trainer Program).

Please email [email protected] to verify that your trainer, consultant, and/or supervisor is approved.

Yes

I don’t know

Name of Trainer(s)

Qualification of Trainer(s)

Have you completed the TF-CBT Web 2.0 online course?

If yes, you will be asked to provide certificate in next question.

Yes

Upload TF-CBT Web 2.0 certificate

Drop files here or

Max. file size: 100 MB.

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.

Yes

Date Live (virtual or in-person) TF-CBT course was completed:

MM slash DD slash YYYY

Number of Live TF-CBT Hours Completed

Upload any supporting documentation about the Live TF-CBT curriculum

Drop files here or

Max. file size: 100 MB.

Description of Training (hours, content)

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.

TF-CBT approved trainer

Supervisor (treatment developer or graduate of the TF-CBT Train-the-Trainer Program, Train-the-Supervisor Program)

Not Applicable

How many hours of consultation were completed?

If it was a supervisor, were they working at the same agency as you at the time?

Yes

Description of Consultation

(frequency / duration / format of case consultation review, e.g. video, audio)

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

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?

Yes

Name of Practitioner #2

First Last

Title

Phone

Degree

Licensure

License Number

Employment status

Staff

Contractor

Independent Practitioner

Certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program? (tfcbt.org)

Yes, Upload Documentation of Certification

Yes, Provide Listing on TF-CBT Certified Therapist page

No, but this information was already uploaded for review

No, this information needs to be uploaded

Upload Documentation of Certification from Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org)

Drop files here or

Max. file size: 100 MB.

Link to your listing on tfcbt.org find a TF-CBT Certified Therapist page https://tfcbt.org/therapists/

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Provide the following information about the training experience for review.

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Is the trainer TF-CBT approved?

(treatment developer or graduate of the TF-CBT Train-the-Trainer Program).

Please email [email protected] to verify that your trainer, consultant, and/or supervisor is approved.

Yes

I don’t know

Name of Trainer(s)

Qualification of Trainer(s)

Have you completed the TF-CBT Web 2.0 online course?

If yes, you will be asked to provide certificate in next question.

Yes

I don’t know

Upload TF-CBT Web 2.0 Certificate

Drop files here or

Max. file size: 100 MB.

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.

Yes

I don’t know

Date Live (virtual or in-person) TF-CBT course was completed:

MM slash DD slash YYYY

Number of Live TF-CBT Hours Completed

Upload any supporting documentation about the Live TF-CBT curriculum

Drop files here or

Max. file size: 100 MB.

Description of Training (hours, content)

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.

TF-CBT approved trainer

Supervisor (treatment developer or graduate of the TF-CBT Train-the-Trainer Program, Train-the-Supervisor Program)

Not Applicable

How many hours of consultation were completed?

If it was a supervisor, were they working at the same agency as you at the time?

Yes

Description of Consultation

(frequency / duration / format of case consultation review, e.g. video, audio)

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

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?

Yes

Name of Practitioner #3

First Last

Title

Phone

Degree

Licensure

License Number

Employment status

Staff

Contractor

Independent Practitioner

Certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program? (tfcbt.org)

Yes, Upload Documentation of Certification

Yes, Provide Listing on TF-CBT Certified Therapist page

No, but this information was already uploaded for review

No, this information needs to be uploaded

Upload Documentation of Certification from Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org)

Drop files here or

Max. file size: 100 MB.

Link to your listing on tfcbt.org find a TF-CBT Certified Therapist page https://tfcbt.org/therapists/

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Provide the following information about the training experience for review.

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Is the trainer TF-CBT approved?

(treatment developer or graduate of the TF-CBT Train-the-Trainer Program).

Please email [email protected] to verify that your trainer, consultant, and/or supervisor is approved.

Yes

I don’t know

Name of Trainer(s)

Qualification of Trainer(s)

Have you completed the TF-CBT Web 2.0 online course?

If yes, you will be asked to provide certificate in next question.

Yes

I don’t know

Upload TF-CBT Web 2.0 certificate

Drop files here or

Max. file size: 100 MB.

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.

Yes

I don’t know

Date Live (virtual or in-person) TF-CBT course was completed:

MM slash DD slash YYYY

Number of Live TF-CBT Hours Completed

Upload any supporting documentation about the Live TF-CBT curriculum

Drop files here or

Max. file size: 100 MB.

Description of Training (hours, content)

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.

TF-CBT approved trainer

Supervisor (treatment developer or graduate of the TF-CBT Train-the-Trainer Program, Train-the-Supervisor Program)

Not Applicable

How many hours of consultation were completed?

If it was a supervisor, were they working at the same agency as you at the time?

Yes

Description of Consultation

(frequency / duration / format of case consultation review, e.g. video, audio)

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

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?

Yes

Name of Practitioner #4

First Last

Title

Phone

Degree

Licensure

License Number

Employment status

Staff

Contractor

Independent Practitioner

Certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program? (tfcbt.org)

Yes, Upload Documentation of Certification

Yes, Provide Listing on TF-CBT Certified Therapist page

No, but this information was already uploaded for review

No, this information needs to be uploaded

Upload Documentation of Certification from Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org)

Drop files here or

Max. file size: 100 MB.

Link to your listing on tfcbt.org find a TF-CBT Certified Therapist page https://tfcbt.org/therapists/

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Provide the following information about the training experience for review.

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Is the trainer TF-CBT approved?

Please email [email protected] to verify that your trainer, consultant, and/or supervisor is approved.

Yes

I don’t know

Name of Trainer(s)

Qualification of Trainer(s)

Have you completed the TF-CBT Web 2.0 online course?

If yes, you will be asked to provide certificate in next question.

Yes

I don’t know

Upload TF-CBT Web 2.0 certificate

Drop files here or

Max. file size: 100 MB.

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.

Yes

Date Live (virtual or in-person) TF-CBT course was completed:

MM slash DD slash YYYY

Number of Live TF-CBT Hours Completed

Upload any supporting documentation about the Live TF-CBT curriculum

Drop files here or

Max. file size: 100 MB.

Description of Training (hours, content)

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.

TF-CBT approved trainer

Supervisor (treatment developer or graduate of the TF-CBT Train-the-Trainer Program, Train-the-Supervisor Program)

Not Applicable

How many hours of consultation were completed?

If it was a supervisor, were they working at the same agency as you at the time?

Yes

Description of Consultation

(frequency / duration / format of case consultation review, e.g. video, audio)

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

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?

Yes

Name of Practitioner #5

First Last

Title

Phone

Degree

Licensure

License Number

Employment status

Staff

Contractor

Independent Practitioner

Certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program? (tfcbt.org)

Yes, Upload Documentation of Certification

Yes, Provide Listing on TF-CBT Certified Therapist page

No, but this information was already uploaded for review

No, this information needs to be uploaded

Upload Documentation of Certification from Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org)

Drop files here or

Max. file size: 100 MB.

Link to your listing on tfcbt.org find a TF-CBT Certified Therapist page https://tfcbt.org/therapists/

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Provide the following information about the training experience for review.

If not certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (tfcbt.org), you are encouraged to complete the certification process.

Is the trainer TF-CBT approved?

(treatment developer or graduate of the TF-CBT Train-the-Trainer Program).

Please email [email protected] to verify that your trainer, consultant, and/or supervisor is approved.

Yes

I don’t know

Name of Trainer(s)

Qualification of Trainer(s)

Have you completed the TF-CBT Web 2.0 online course?

If yes, you will be asked to provide certificate in next question.

Yes

Upload TF-CBT Web 2.0 certificate

Drop files here or

Max. file size: 100 MB.

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.

Yes

Date Live (virtual or in-person) TF-CBT course was completed:

MM slash DD slash YYYY

Number of Live TF-CBT Hours Completed

Upload any supporting documentation about the Live TF-CBT curriculum

Drop files here or

Max. file size: 100 MB.

Description of Training (hours, content)

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.

TF-CBT approved trainer

Supervisor (treatment developer or graduate of the TF-CBT Train-the-Trainer Program, Train-the-Supervisor Program)

Not Applicable

How many hours of consultation were completed?

If it was a supervisor, were they working at the same agency as you at the time?

Yes

Description of Consultation

(frequency / duration / format of case consultation review, e.g. video, audio)

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

Drop files here or

Max. file size: 100 MB.

Additional Practitioners in this EBP?

Yes

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

Please submit application and additional practitioners can be listed on a second provider application.

Training Calendar

Training Catalog

Trauma Focused Cognitive Behavior Therapy (TF-CBT) EBP Provider Qualification Questionnaire

Staff Roster and Certification Information

Contact

Mailing Address

Physical Address