DIALECTICAL BEHAVIOR THERAPY INTENSIVE TRAINING™ Team Application Part 1 June 13-17, 2016 ▪ Part 2 January 23-27, 2017 Hyannis, MA APPLICATIONS DUE BY Monday, April 25, 2016 Please complete the Team Application and return to BTECH at info@behavioraltech.org. 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 Assertive Community Treatment (ACT) Case management Clinical supervision of other clinicians Crisis intervention Drug/alcohol counseling Group psychoeducation Group psychotherapy Individual psychotherapy Pharmacotherapy Skills training Training/education/support to family members Training/education/support to other professionals Other Please describe. Does your organization currently provide DBT or components of DBT? If yes, please describe: Yes No How would you rate your organization/program’s familiarity of DBT? Not Familiar At All Slightly Familiar Somewhat Familiar Moderately Familiar Extremely Familiar What are the strengths of your organization/program? How is your organization/program preparing to orient other staff members to your DBT program (e.g., front line staff, administration)? Please describe how your attendance at the Dialectical Behavior Therapy Intensive TrainingTM will help meet your organization/agency’s goals for the future: DBT Changes Lives. Behavioral Tech is a Linehan Institute training company. 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) Team Member 1. List All Planned Roles in DBT Program (e.g., Skills trainer, Coach, Individual Therapy, Pharmacotherapist) 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. Name Please select all services your team provides (check all that apply): Administrative supervision of others Assertive Community Treatment (ACT) Case management Clinical supervision of other clinicians Crisis intervention Drug/alcohol counseling Group psychoeducation Group psychotherapy Individual psychotherapy Pharmacotherapy Skills training Training/education/support to family members Training/education/support to other professionals Other Please describe. 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 Adolescents LGBT Adults Males Page 2 Females Ethnic minorities Low income populations How many clients are treated by your team PER WEEK: Total Clients: Clients with borderline personality disorder: Chronically suicidal clients (i.e., chronic suicide ideation, repetitive suicide threats): Self-injuring clients (i.e., self-harm without intent to die): High utilizers of crisis services (e.g., ED, inpatient psychiatry): 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. 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. Whether starting a new DBT program or building on an existing one, what limitations or barriers do you foresee your team experiencing? Click here to enter text. Describe your plan for your DBT Consultation Team meetings (e.g., meeting schedule, location, roles). 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. Page 3