DIALECTICAL BEHAVIOR THERAPY INTENSIVE TRAINING™
Team Application
Part 1: March 14-18, 2016 ▪ Part 2: September 26-30, 2016
Seattle, WA
APPLICATIONS DUE BY Friday, January 22, 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 Training TM will help meet your
organization/agency’s goals for the future:
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.
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
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):
Linehan Institute – Behavioral Tech | 1107 NE 45th Street, Suite 230 | Seattle, WA 98105 | Phone 206.675.8588 | www.behavioraltech.org
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Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization.
Please describe the client population with which your team works:
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How long have your team members known each other?
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How long has your team worked together?
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Why is your team pursuing Dialectical Behavior Therapy Intensive Training™ at this point in time?
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List one or two specific goals your team has for this training.
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Whether starting a new DBT program or building on an existing one, what limitations or barriers do you foresee your
team experiencing?
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Describe your plan for your DBT Consultation Team meetings (e.g., meeting schedule, location, roles).
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Describe your plan for conducting program evaluation/research on your DBT services.
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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?
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Linehan Institute – Behavioral Tech | 1107 NE 45th Street, Suite 230 | Seattle, WA 98105 | Phone 206.675.8588 | www.behavioraltech.org
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Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization.