TF-CBT EBP Provider Qualification Questionnaire

New Mexico Evidence Based Practices
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT EBP Provider Qualification Questionnaire

Please complete application below and provide all requested information to determine if you meet New Mexico qualification standards for TF-CBT. Please allow up to 30 days for review of your application. Approved providers will be sent necessary documentation for updating your Medicaid profile and MCO contracts.

For more details on qualification standards please download the New Mexico EBP Training and Qualification Guide.

Step 1 of 7

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I. Contact Information

The information below is for the purpose of contact only. Information does not transfer to staff roster. If point of contact is a provider practicing the EBP, then list on section III.

Point of Contact Name

First Last

Title

Phone

Agency Name

Agency address

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in a secondary location?

If so, provide address.

Yes

Additional address

Street Address Address Line 2 City State ZIP Code

Agency Executive Name

First Last

Title

Phone

II. Agency Service Data

Primary County of Service

Serve additional counties?

Yes

Additional Counties Served

Type each county served, separate with comma.

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

Yes

Level of care or service where TF-CBT is delivered

Outpatient

School-based

Residential

Community-based

Other

Agency is current funded by/contracted with the following:

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

Agency NPI

Medicaid Enrollment ID

III. Staff Roster and Certification

List each qualified staff member at the agency.

If clinicians and supervisors are not certified through the listed entity, additional information about the qualifications of the trainer, the training and consultation received, and attach supporting documentation are requested.

Name of Practitioner #1

First Last

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Is the practitioner certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program?(Required)

Visit TFCBT.org to learn more about certification.

Yes

Upload Proof of Certification(Required)

Please use this section to upload the official certificate from the Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program (www.tfcbt.org).

Please DO NOT submit a Continuing Education certificate or a certificate of completion of the TF-CBT Web 2.0 online training here.

If you are uncertain if you have a certification from the Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program, please select “no” to the previous question and fill out the additional training description questions.

Drop files here or

Max. file size: 100 MB.

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

Provide the following information about the training experience for review.

Has the practitioner completed the TF-CBT Web 2.0 online course?(Required)

If yes, provide proof of certificate.

Yes

Upload Proof of TF-CBT Web 2.0 Certification

Visit TF-CBT Web 2.0 Homepage If you don't have access to certificate please still submit and you can send separately at a later date. Please email their web administrator at [email protected] to inquire how to obtain another copy.

Drop files here or

Max. file size: 100 MB.

Has the practitioner completed the live (virtual or in-person) 2 day (or equivalent amount of time) TF-CBT course?(Required)

If yes, provide date, hours completed, and additional documentation.

Yes

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

Month/year. Estimate if you are not sure.

Number of Live TF-CBT Training Hours Completed (length of training)(Required)

Upload Live TF-CBT supporting training documentation

Drop files here or

Max. file size: 100 MB.

Was the TF-CBT training led by a TF-CBT approved trainer?(Required)

The trainer must be a treatment developer or graduate of the TF-CBT Train-the-Trainer Program.

Email [email protected] to verify the trainer is TF-CBT approved.

Yes

Name of Trainer(s)

Description of Training (hours, content)

Upload supporting training documentation

Drop files here or

Max. file size: 100 MB.

Has the practitioner participated in a TF-CBT consultation group?(Required)

The consultant or supervisor must be a treatment developer, graduate of the TF-CBT Train-the-Trainer Program or a graduate of the TF-CBT Train-the-Supervisor Program and be employed at the same agency as the trainee.

Email [email protected] to verify the consultant, and/or supervisor is TF-CBT approved.

Yes

Name of Consultant(s)

Consultation Start Date

Frequency of Consultation

Once per month for 12 months or twice a month for 6 months.

Total Hours of Consultation Completed

Description of Consultation

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

Additional Practitioners in this EBP?

Yes

Name of Practitioner #2

First Last

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Is the practitioner certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program?(Required)

Visit TFCBT.org to learn more about certification.

Yes

Upload Proof of Certification(Required)

Drop files here or

Max. file size: 100 MB.

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

Provide the following information about the training experience for review.

Has the practitioner completed the TF-CBT Web 2.0 online course?(Required)

If yes, provide proof of certificate.

Yes

Upload Proof of TF-CBT Web 2.0 Certification

Drop files here or

Max. file size: 100 MB.

Has the practitioner completed the live (virtual or in-person) 2 day (or equivalent amount of time) TF-CBT course?(Required)

If yes, provide date, hours completed, and additional documentation.

Yes

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

Month/year. Estimate if you are not sure.

Number of Live TF-CBT Training Hours Completed (length of training)(Required)

Upload Live TF-CBT supporting training documentation

Drop files here or

Max. file size: 100 MB.

Was the TF-CBT training led by a TF-CBT approved trainer?(Required)

The trainer must be a treatment developer or graduate of the TF-CBT Train-the-Trainer Program.

Email [email protected] to verify the trainer is TF-CBT approved.

Yes

Name of Trainer(s)

Description of Training (hours, content)

Upload supporting training documentation

Drop files here or

Max. file size: 100 MB.

Has the practitioner participated in a TF-CBT consultation group?(Required)

Yes

Name of Consultant(s)

Consultation Start Date

Frequency of Consultation

Once per month for 12 months or twice a month for 6 months.

Total Hours of Consultation Completed

Description of Consultation

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

Additional Practitioners in this EBP?

Yes

Name of Practitioner #3

First Last

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Is the practitioner certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program?(Required)

Visit TFCBT.org to learn more about certification.

Yes

Upload Proof of Certification(Required)

Drop files here or

Max. file size: 100 MB.

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

Provide the following information about the training experience for review.

Has the practitioner completed the TF-CBT Web 2.0 online course?(Required)

If yes, provide proof of certificate.

Yes

Upload Proof of TF-CBT Web 2.0 Certification

Drop files here or

Max. file size: 100 MB.

Has the practitioner completed the live (virtual or in-person) 2 day (or equivalent amount of time) TF-CBT course?(Required)

If yes, provide date, hours completed, and additional documentation.

Yes

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

Month/year. Estimate if you are not sure.

Number of Live TF-CBT Training Hours Completed (length of training)(Required)

Upload Live TF-CBT supporting training documentation

Drop files here or

Max. file size: 100 MB.

Was the TF-CBT training led by a TF-CBT approved trainer?(Required)

The trainer must be a treatment developer or graduate of the TF-CBT Train-the-Trainer Program.

Email [email protected] to verify the trainer is TF-CBT approved.

Yes

Name of Trainer(s)

Description of Training (hours, content)

Upload supporting training documentation

Drop files here or

Max. file size: 100 MB.

Has the practitioner participated in a TF-CBT consultation group?(Required)

Yes

Name of Consultant(s)

Consultation Start Date

Frequency of Consultation

Once per month for 12 months or twice a month for 6 months.

Total Hours of Consultation Completed

Description of Consultation

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

Additional Practitioners in this EBP?

Yes

Name of Practitioner #4

First Last

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Is the practitioner certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program?(Required)

Visit TFCBT.org to learn more about certification.

Yes

Upload Proof of Certification(Required)

Drop files here or

Max. file size: 100 MB.

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

Provide the following information about the training experience for review.

Has the practitioner completed the TF-CBT Web 2.0 online course?(Required)

If yes, provide proof of certificate.

Yes

Upload Proof of TF-CBT Web 2.0 Certification

Drop files here or

Max. file size: 100 MB.

Has the practitioner completed the live (virtual or in-person) 2 day (or equivalent amount of time) TF-CBT course?(Required)

If yes, provide date, hours completed, and additional documentation.

Yes

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

Month/year. Estimate if you are not sure.

Number of Live TF-CBT Training Hours Completed (length of training)(Required)

Upload Live TF-CBT supporting training documentation

Drop files here or

Max. file size: 100 MB.

Was the TF-CBT training led by a TF-CBT approved trainer?(Required)

The trainer must be a treatment developer or graduate of the TF-CBT Train-the-Trainer Program.

Email [email protected] to verify the trainer is TF-CBT approved.

Yes

Name of Trainer(s)

Description of Training (hours, content)

Upload supporting training documentation

Drop files here or

Max. file size: 100 MB.

Has the practitioner participated in a TF-CBT consultation group?(Required)

Yes

Name of Consultant(s)

Consultation Start Date

Frequency of Consultation

Once per month for 12 months or twice a month for 6 months.

Total Hours of Consultation Completed

Description of Consultation

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

Additional Practitioners in this EBP?

Yes

Name of Practitioner #5

First Last

Title

Phone

Degree

Licensure

Licensure Number

Employment status

Staff

Contractor

Independent Practitioner

Is the practitioner certified by Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program?(Required)

Visit TFCBT.org to learn more about certification.

Yes

Upload Proof of Certification(Required)

Drop files here or

Max. file size: 100 MB.

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

Provide the following information about the training experience for review.

Has the practitioner completed the TF-CBT Web 2.0 online course?(Required)

If yes, provide proof of certificate.

Yes

Upload Proof of TF-CBT Web 2.0 Certification

Drop files here or

Max. file size: 100 MB.

Has the practitioner completed the live (virtual or in-person) 2 day (or equivalent amount of time) TF-CBT course?(Required)

If yes, provide date, hours completed, and additional documentation.

Yes

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

Month/year. Estimate if you are not sure.

Number of Live TF-CBT Training Hours Completed (length of training)(Required)

Upload Live TF-CBT supporting training documentation

Drop files here or

Max. file size: 100 MB.

Was the TF-CBT training led by a TF-CBT approved trainer?(Required)

The trainer must be a treatment developer or graduate of the TF-CBT Train-the-Trainer Program.

Email [email protected] to verify the trainer is TF-CBT approved.

Yes

Name of Trainer(s)

Description of Training (hours, content)

Upload supporting training documentation

Drop files here or

Max. file size: 100 MB.

Has the practitioner participated in a TF-CBT consultation group?(Required)

Yes

Name of Consultant(s)

Consultation Start Date

Frequency of Consultation

Once per month for 12 months or twice a month for 6 months.

Total Hours of Consultation Completed

Description of Consultation

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

Additional Practitioners in this EBP?

Yes

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

Please email [email protected] if TF-CBT team is greater than five.

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TF-CBT EBP Provider Qualification Questionnaire

I. Contact Information

II. Agency Service Data

III. Staff Roster and Certification

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