Dialectical Behavior Therapy Intensive Training

Dialectical Behavior Therapy Intensive Training™

Annenburg public Beach House, SANTA MONICA, CA
Team Application

Please complete the Team Application and return to BTECH at .
Submit your team and individual applications ASAP. Notification of Acceptance will be sent no later than September 4, 2017.

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):

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

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? YesNo

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

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 services your team provides (check all that apply):

Linehan Institute – Behavioral Tech | 1107 NE 45th Street, Suite 230 | Seattle, WA 98105 | Phone 206.675.8588 |
Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization.

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

College/University counseling service

Community Mental Health Center

Developmental disability program

Elementary/secondary education

Forensic/correctional services

Group home

Independent/private practice

Inpatient

Integrated co-occurring disorders program

Intensive day treatment/partial hospitalization

Outpatient clinic

Residential facility

Other Please describe.

Please select all populations with whom your team works (check all that apply):

Children

Adolescents

Adults

Geriatric

LGBT

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):

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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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

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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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