Dialectical Behavioral Therapy (DBT) Summit Presentation Proposal Form
May 5, 2017
Grand Traverse Resort, Traverse City, Michigan
Presentation Submission Form: Deadline Monday, March 3, 2017
Purpose of this form: Training program planners at MACMHB use the information requested in this form for several things – to assure appropriateness of content; to assess whether the presentation meets criteria for social work “Continuing Education Clock Hours,” and/or substance abuse professional certification “Contact Hours”; to develop program description and learning objectives for the brochure. Description and learning objectives may be edited and formatted for inclusion in program brochure.
· Complete this form [electronically] and save it as a document.
· Required to Send: 1) completed submission form and 2) a resume for each presenter.
· Return via email to by Friday, March 3, 2017.
· We allow for a maximum of 3 presenters during a workshop.
· Workshops are generally 90 minutes; a small number of double sessions may be considered.
· Presenter Compensation: The summit budget will not provide honorariums for workshop presenters. Presenters will receive a complimentary registration for their presentation. One car per session will receive mileage for in-state travel mileage. Presenters that travel more than 100 miles hours to the summit, he/she will also receive a one-night stay at the Grand Traverse Resort, Traverse City. If presenters are not able to participate due to lack of reimbursement, special arrangements may be made with MACMHB when you are notified of your accepted proposal.
Proposed Time:Check all your availability / May 5, 2017 Morning (10:00am – 11:30am)
May 5, 2017 Afternoon (1:30pm – 3:00pm)
May 5, 2017 Afternoon (3:15pm – 4:45pm)
Target Audience: / Clinical Peer Support Specialist
Administrative/Executive Leadership
Check all that apply: / Targeted Experience Level: Entry Level Intermediate Advanced
Social Workers: Macro [administrative] Micro [clinical]
Presentation Title to be Listed in Brochure:
QUANTIFIABLE LEARNING OBJECTIVES [include a MINIMUM of 3 - MAXIMUM of 4]
Use such words as: define, memorize, repeat, record, list, recall, name, relate, specify, cite, recount, restate, summarize,
discuss, describe, recognize, explain, express, identify, translate, exhibit, solve, apply, employ, use, demonstrate, illustrate, operate, calculate, show, experiment, interpret, classify, differentiate, group, compare, organize, contrast, examine, categorize
EXAMPLE – Participants will be able to 1) identify a working definition of Trauma; 2) Repeat 2 common reactions of Trauma in each of 5 life domains;3) list 4 standards for Trauma Informed services for your organization; 4) describe the 3 Stages of Healing; and 5) list the 4 steps in every session.
Participants will be able to:
1.
2.
3.
Presentation Description – Please provide a brief description (5-7 sentences) of the proposed presentation that we may use for promotional purposes.
Description: Limit of 175 words.
You MUST select ONE track that your proposed workshop best fits.
o Emerging and Evidence-Based Practices
o Adaptations in DBT (i.e. DBT-SUD, DBT-DD, DBT-ED)
o Outcomes Data and Process Monitoring
o Stage II Treatment
o Penetration Rates
o Use of Peer Support Specialists
o Telephonic Skills Coaching
o Consultation Team
o Pre-Treatment Strategies (i.e. commitment strategies, treatment planning, orienting strategies, etc.)
o Advanced DBT for Graduates
o DBT in Individual Therapy (i.e. behavioral chain analysis, targeting strategies, case conceptualization, etc.)
o DBT for Administrative Staff
o Other (specify):
What are the topics / sections to be covered?
Topics:
Bibliography: Please identify where material for this presentation is drawn from. You may attach a separate bibliography or use additional pages if necessary.
Bibliography:
References – Please identify presentations you have previously delivered on this or related topics unless included on your resume:
Previous Trainings:
Primary Presenter Information:
Name:
Degrees/Credentials:
Title:
Organization:
Address:
Phone Number: / Fax Number:
Email Address:
Co-Presenters Information (if applicable):
Name:
Degrees/Credentials:
Title:
Organization:
Address:
Phone Number: / Fax Number:
Email Address:
Continue to add Presenter Information as Needed.
Submit all materials by March 3, 2017 to Annette Pepper at