TBT-S Post-Level 3 Consultation Request Form
Quarterly Group Consultations on Integration of TBT-S into your practice
Date
-
Month
-
Day
Year
Date you are completing form.
Contact and Professional Demographic Information
Name
*
First Name
Last Name and Degree
Professional Degree
Type the letters, e.g., PhD, LSW
Email
*
Address
Business, University, Medical Center, private practice etc. name
Street or PO and/or Suite
City
State / Province/ Country
Postal / Zip Code
Phone Number
*
Country and Area Code + number
What is your Profession?
*
Psychologist
Social Worker
Counselor
Mental Health Practitioner
Occupational Therapist
Nurse
Physician
Dietitian
Medical Practitioner
Faculty/Teacher
Other
Type of Business
*
Hospital
University/Educational Setting
Private Practice
Out Patient Treatment Program
Clinical Team within a Treatment Setting
Mental Health Program
Other
If you are applying on behalf of a clinical team, please describe the team members and business setting who will participate in these 2 hour consultation segments to integrate TBT-S into practice.
Prerequisites: Check all that are true for you:
Read "Temperament Based Therapy with Supports" book by Hill, Peck and Wierenga, 2022.
Completed Level 1 or face-to-face training.
Attended a Level 2 training face-to-face training
Completed Level 3 adolescent or adult consultations
TBT-S is a Training Institute, not a treatment facility. It is not liable for the treatment provided in your professional setting. Do you agree to not hold TBT-S Training Institute liable for the treatment and educational outreach that you provide?
*
I agree
I don't agree
We will get back to you regarding days/dates and time options
Thank you for your interest!
Submit
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