4
EARLY START DENVER MODEL TRAINING
ADVANCED COURSE TEAM APPLICATION
Please supply all requested information; a complete application is required for full consideration.
Name of Service, Program, or Team:
Name of Main Point of Contact (POC):
Address of Service, Program, or Team:
Please provide names of team members who will participate in the training (3-5 members)*, contact information, current degrees held, and professional background – psychologist, speech pathologist, occupational therapist, early interventionist, etc.
*Priority for acceptance is given to team applications.
Main POC or Team Member #1 Name:
Professional Background/Job Title:
Mailing Address:
Email Address:
Phone:
Highest Earned Degree & Certifications:
Number of Direct Therapy/Treatment Hours You Provide Weekly :
Team Member #2 Name:
Professional Background/Job Title:
Mailing Address:
Email Address:
Phone:
Highest Earned Degree & Certifications:
Number of Direct Therapy/Treatment Hours You Provide Weekly :
Team Member #3 Name:
Professional Background/Job Title:
Mailing Address:
Email Address:
Phone:
Highest Earned Degree & Certifications:
Number of Direct Therapy/Treatment Hours You Provide Weekly :
Team Member #4 Name:
Professional Background/Job Title:
Mailing Address:
Email Address:
Phone:
Highest Earned Degree & Certifications:
Number of Direct Therapy/Treatment Hours You Provide Weekly :
Team Member #5 Name:
Professional Background/Job Title:
Mailing Address:
Email Address:
Phone:
Highest Earned Degree & Certifications:
Number of Direct Therapy/Treatment Hours You Provide Weekly :
Describe your core program/service details relative to young children diagnosed with an Autism Spectrum Disorder, or at risk of a diagnosis.
Why do you want to participate in this training program?
How do you propose providing training to other teams?
How is your program funded? Check applicable sources:
□ State government funding
□ Client fees
□ Fundraising and Sponsorship
□ Federal government funding
□Medicare rebates
□ Other, please specify: ______
By signing below you acknowledge that, if successful in being selected for the training workshop, you and your team:
· Work regularly with 12-60 month-old children with ASD
· All team members have educational degrees beyond a bachelor's (e.g., MA, Ph.D., MFT, SLP, OT)
· Have completed or are enrolled in the ESDM Intro Workshop
· Have purchased, read and will bring a copy of the manual, “Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement” and the “Early Start Denver Model Curriculum Checklist” (sold separately) to this Workshop
· Will submit three rounds of training materials within the specified timelines for certification review in the Advanced Workshop (for specific requirements, please see http://www.ucdmc.ucdavis.edu/mindinstitute/research/esdm/pdf/certification_steps.pdf
Signed ______Date: _____/_____/_____
Print Name ______
Please email your application to:
185 Lincoln Street, Suite 205
Hingham, MA 02043
(781)749-3606
www.southshorepsych.com