Bucks County Behavioral Health
Magellan Behavioral Health of Pennsylvania, Inc.
Application for Trauma Focused Cognitive Behavioral Treatment (TF-CBT) Training & Certification Program
Staff Name:
Staff Degree & Credentials:
Staff Phone:
Staff Email Address:
Agency/Facility Name:
Staff Position:
Agency Point Person:
Agency Team of Trainees:
Staff Hire Date:
Do you Work Full or Part Time:
Staff Level of Care:
Full Time
Part Time: # of Hours per Week Worked at this Agency:
Current Caseload of Members under 18 Years of Age:
Which of the following do you Work with:
HealthChoices Population
Commercial Population
Both: Estimated % of Work Hours Devoted to HealthChoices:
Population(s) Whom you Work with:
Juvenile Justice Youth
Other:
Children
Adolescents
Dually Diagnosed Member
Adults
Children and Youth Members
Drug and Alcohol Members
Identify any Trauma Specific Trainings/Certifications you have Attended/Received:
Identify any other Specialties/Certifications you have Received:
Indicate the reasons you would like to be involved in the TF-CBT Training Program and what you hope to gain from the training:
By initialing below, you are agreeing to complete these required items within the given timeframe (as applicable).
I agree to complete the Brief TF-CBT Overview Training available on line at www.musc.edu/tfcbt prior to April 13, 2016.
I agree to attend in full the two day TF-CBT training session on April 14 & April 15, 2016.
I agree to identify two youth to begin TF-CBT treatment immediately following the April 14 & 15, 2016 training.
I agree to complete three separate TF-CBT treatment cases with three children or adolescents with at least two of the
cases including the active participation of caretakers by January 2017.
I agree to utilize at least one standardized instrument to assess TF-CBT treatment progress with each of the above cases.
Magellan and Bucks County require that the Trauma History Questionnaire Screening tool and Child PTSD Symptom Scale
(CPSS) be the tools used during treatment.
I agree to actively participate in one hour consultation calls twice per month for 12 months.
I agree to attend the advanced clinical training session in 2016.
I agree to complete Part I of the Certification Application Program and pay the $125 fee by December 15, 2016.
I agree to complete Part II of the Certification Application Program and pay the $125 fee by February 15, 2017.
I agree to take the TF-CBT Therapist Certification Program Knowledge-Based Test by March 15, 2017.
I agree to inform Magellan and Bucks County when I pass the TF-CBT test and receive certification.
Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is a affiliate of Magellan Healthcare, Inc.
Rev: 12/9/2015
TF-CBT Application Continued
Page 2 of 2
Staff Signature
Date
BELOW TO BE COMPLETED BY AGENCY DIRECTOR
Please indicate through your signature and comments, your agency’s willingness to support this staff person’s participation in the
TF-CBT program through accommodation for attending trainings, participating in consultation calls, and other avenues of support
for implementation of the model. Please include a recommendation for this staff’s participation in the training program.
Agency Director’s Signature (Indicating Approval):
Agency Director’s Recommendations:
Identify any Trauma Specific Trainings/Certifications/Initiatives your Agency has participated in:
Agency Director’s Plan for Supporting Implementation of a TF-CBT service delivery model:
Indicate how your agency will support staff in completing TF-CBT certification requirements:
Magellan Behavioral Health of Pennsylvania, Inc. (Magellan) is a affiliate of Magellan Healthcare, Inc.
Rev: 12/9/2015