Dialectical Behavior Therapy Intensive Training

DIALECTICAL BEHAVIOR THERAPY INTENSIVE TRAINING™ TEAM APPLICATION N Part 1 April 30 – May 4 | Part 2 December 3-7, 2018 Co-Hosted by: County of Napa, Behavioral Health Team application bundles will be reviewed in the order in which they are received. APPLICATIONS DUE FRIDAY, APRIL 1, 2016 Please complete the Team Application and return to BTECH at [email protected].

ORGANIZATION INFORMATION

For what agency or organization do you currently work?

How many clients are treated per week by your: Organization: Program/Department:

Please select all services your organization provides (check all that apply):

Administrative supervision of others Group psychotherapy

Assertive Community Treatment (ACT) Individual psychotherapy Case management Pharmacotherapy

Clinical supervision of other clinicians Skills training Crisis intervention Training/education/support to family members

Drug/alcohol counseling Training/education/support to other professionals Group psychoeducation Other Please describe.

Does your organization currently provide DBT or components of DBT? Yes No If yes, please describe:

How would you rate your organization/program’s familiarity of DBT? Not Familiar At All

Slightly Familiar

Somewhat Familiar

Moderately Familiar

Extremely Familiar

Linehan Institute – Behavioral Tech | 1107 NE 45th Street, Suite 230 | Seattle, WA 98105 | Phone 206.675.8588 | www.behavioraltech.org Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization. Please describe how your attendance at the Dialectical Behavior Therapy Intensive TrainingTM will help meet your organization/agency’s goals for the future:

TEAM INFORMATION

What is the name of your DBT Team?

Team Contact Information: Team Leader: Phone Number: Email Address:

Names of Team Members: (minimum of three members to maximum eight members, including leader)

Name List All Planned Roles in DBT Program (e.g., Skills trainer, Coach, Individual Therapy, Pharmacotherapist) Team Member 1. Enter role. Team Member 2. Enter role. Team Member 3. Enter role. Team Member 4. Enter role. Team Member 5. Enter role. Team Member 6. Enter role. Team Member 7. Enter role. Team Member 8. Enter role.

Please select all settings in which your team works (check all that apply):

Chemical dependency program Independent/private practice

College/University counseling service Inpatient Community Mental Health Center Integrated co-occurring disorders program

Developmental disability program Intensive day treatment/partial hospitalization Elementary/secondary education Outpatient clinic

Forensic/correctional services Residential facility Group home Other Please describe.

Please select all populations with whom your team works (check all that apply): Children Geriatric Females Adolescents LGBT Ethnic minorities

Adults Males Low income populations Please describe the client population with which your team works: Click here to enter text. How long have your team members known each other? Click here to enter text. 2 How long has your team worked together? Click here to enter text. Why is your team pursuing Dialectical Behavior Therapy Intensive Training™ at this point in time? Click here to enter text. List one or two specific goals your team has for this training. Click here to enter text. Describe your plan for your DBT Consultation Team meetings (e.g., meeting schedule, location, roles). It is recommended that you begin meeting as a team prior to part I if you are not currently doing so Click here to enter text.

Describe your plan for conducting program evaluation/research on your DBT services. Click here to enter text.

The Dialectical Behavior Therapy Intensive Training™ application process is competitive. What other information would you like to provide about your team in support of your application? Click here to enter text.

3 Linehan Institute – Behavioral Tech | 4746 11th Ave NE Suite 102 | Seattle, WA 98105 | Phone 206.675.8588 | www.behavioraltech.org Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization.