TF-CBT Interest Form

New Mexico Evidence Based Practices
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
TF-CBT Interest Form

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

Primary Address 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.

What population does your agency currently serve?(Required)

Check all that apply

Children

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 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 (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)

Email(Required)

Phone(Required)

II. Staff Information

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

Name of Practitioner #1(Required)

First Last

Email(Required)

Current TF-CBT Status(Required)

Visit TF-CBT to learn more about certification.

Check all that apply.

No TF-CBT training

Completed TF-CBT Web 2.0 online training

Completed 2-day TF-CBT training

Completed TF-CBT case consultation

Completed cases necessary for TF-CBT certification

Applied for TF-CBT Certification

Anything else you would like to tell us about your training or experience with TF-CBT?

Anything else you would like to tell us about your interest in TF-CBT training?

Additional Practitioners interested in this EBP?(Required)

Yes

Name of Practitioner #2(Required)

First Last

Email(Required)

Current TF-CBT Status(Required)

Visit TF-CBT to learn more about certification.

Check all that apply.

No TF-CBT training

Completed TF-CBT Web 2.0 online training

Completed 2-day TF-CBT training

Completed TF-CBT case consultation

Completed cases necessary for TF-CBT certification

Applied for TF-CBT Certification

Anything else you would like to tell us about your training or experience with TF-CBT?

Anything else you would like to tell us about your interest in TF-CBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #3(Required)

First Last

Email(Required)

Current TF-CBT Status(Required)

Visit TF-CBT to learn more about certification.

Check all that apply.

No TF-CBT training

Completed TF-CBT Web 2.0 online training

Completed 2-day TF-CBT training

Completed TF-CBT case consultation

Completed cases necessary for TF-CBT certification

Applied for TF-CBT Certification

Anything else you would like to tell us about your training or experience with TF-CBT?

Anything else you would like to tell us about your interest in TF-CBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #4(Required)

First Last

Email(Required)

Current TF-CBT Status(Required)

Visit TF-CBT to learn more about certification.

Check all that apply.

No TF-CBT training

Completed TF-CBT Web 2.0 online training

Completed 2-day TF-CBT training

Completed TF-CBT case consultation

Completed cases necessary for TF-CBT certification

Applied for TF-CBT Certification

Anything else you would like to tell us about your training or experience with TF-CBT?

Anything else you would like to tell us about your interest in TF-CBT training?

Additional Practitioners in this EBP?(Required)

Yes

Name of Practitioner #5(Required)

First Last

Email(Required)

Current TF-CBT Status(Required)

Visit TF-CBT to learn more about certification.

Check all that apply.

No TF-CBT training

Completed TF-CBT Web 2.0 online training

Completed 2-day TF-CBT training

Completed TF-CBT case consultation

Completed cases necessary for TF-CBT certification

Applied for TF-CBT Certification

Anything else you would like to tell us about your training or experience with TF-CBT?

Anything else you would like to tell us about your interest in TF-CBT 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.

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TF-CBT Interest Form

I. Agency Service Data

II. Staff Information

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