TF-CBT Specialty Provider Rate Application

I. Agency Service Data

Agency Name(Required)

Primary County of Service(Required)

Primary Address Medicaid Enrollment ID

Primary Agency Address(Required)

Street Address Address Line 2 City State ZIP Code

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

Yes

No

Second County of Service(Required)

Second Address Medicaid Enrollment ID

Second Address EBP is delivered(Required)

Street Address Address Line 2 City State ZIP Code

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

Yes

No

Level of care or service where TF-CBT is delivered(Required)

Outpatient

School-based

Residential

Community-based

Other

Please describe level of care or service where TF-CBT 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 (Turquoise Care)

MCO-Molina Healthcare (Turquoise Care)

MCO-Presbyterian Health Plan (Turquoise Care)

MCO-United Healthcare (Turquoise Care)

NM Medicaid Fee for Service

Direct Contract with CYFD

Direct Contract with BHSD

Other

Other funding/contract(Required)

Point of Contact First Name(Required)

Point of Contact Last Name(Required)

Title(Required)

Phone(Required)

Email(Required)

Any additional or clarifying information about current TF-CBT services your agency provides

You will provide practitioner name and qualification information on the following page.

II. Staff Roster and Qualification

List each qualified staff member at the agency.

First Name of Practitioner #1(Required)

First

Last Name of Practitioner #1(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Licensure Upload

Upload current license

Drop files here or

Max. file size: 100 MB.

License Issue Date(Required)

Certification Issue Date(Required)

Certification Expiration Date

Employment status(Required)

Staff

Contractor

Independent Practitioner

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Practitioner NPI(Required)

Upload certificate of completion of TF-CBT Certification Program(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.

Drop files here or

Max. file size: 100 MB.

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

Email tf-cbt@ahn.org to verify the trainer is TF-CBT approved.

Additional Practitioners in this EBP?(Required)

Yes

No

First Name of Practitioner #2(Required)

First

Last Name of Practitioner #2(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Licensure Upload

Upload current license

Drop files here or

Max. file size: 100 MB.

License Issue Date(Required)

Certification Issue Date(Required)

Certification Expiration Date

Employment status(Required)

Staff

Contractor

Independent Practitioner

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Practitioner NPI(Required)

Upload certificate of completion of TF-CBT Certification Program(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.

Drop files here or

Max. file size: 100 MB.

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

Email tf-cbt@ahn.org to verify the trainer is TF-CBT approved.

Additional Practitioners in this EBP?(Required)

Yes

No

First Name of Practitioner #3(Required)

First

Last Name of Practitioner #3(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Licensure Upload

Upload current license

Drop files here or

Max. file size: 100 MB.

License Issue Date(Required)

Certification Issue Date(Required)

Certification Expiration Date

Employment status(Required)

Staff

Contractor

Independent Practitioner

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Practitioner NPI(Required)

Upload certificate of completion of TF-CBT Certification Program(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.

Drop files here or

Max. file size: 100 MB.

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

Email tf-cbt@ahn.org to verify the trainer is TF-CBT approved.

Additional Practitioners in this EBP?(Required)

Yes

No

First Name of Practitioner #4(Required)

First

Last Name of Practitioner #4(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Licensure Upload

Upload current license

Drop files here or

Max. file size: 100 MB.

License Issue Date(Required)

Certification Issue Date(Required)

Certification Expiration Date

Employment status(Required)

Staff

Contractor

Independent Practitioner

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Practitioner NPI(Required)

Upload certificate of completion of TF-CBT Certification Program(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.

Drop files here or

Max. file size: 100 MB.

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

Email tf-cbt@ahn.org to verify the trainer is TF-CBT approved.

Additional Practitioners in this EBP?(Required)

Yes

No

First Name of Practitioner #5(Required)

First

Last Name of Practitioner #5(Required)

Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Licensure Upload

Upload current license

Drop files here or

Max. file size: 100 MB.

License Issue Date(Required)

Certification Issue Date(Required)

Certification Expiration Date

Employment status(Required)

Staff

Contractor

Independent Practitioner

Do you serve the following populations?(Required)

Check all that apply

Children

Adolescents

Adults

Practitioner NPI(Required)

Upload certificate of completion of TF-CBT Certification Program(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.

Drop files here or

Max. file size: 100 MB.

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

Email tf-cbt@ahn.org to verify the trainer is TF-CBT approved.

Additional Practitioners in this EBP?(Required)

Yes

No

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

Please email centerofinnovationnm@nmsu.edu if EMDR team is greater than five.

TF-CBT Specialty Provider Rate Application

Application

I. Agency Service Data

II. Staff Roster and Qualification

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