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.

Which populations does the TF-CBT team 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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