Lilac Center Fellowship Application Form

Lilac Center Fellowship Application Form

Please complete this form to apply to Lilac Center Fellowship Program.
Personal Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com

Professional Experience
Current Position Organization
Role
Duration
Previous Position Organization
Role
Duration
Clinical Experience
Describe your experience with Dialectical Behavior Therapy or other therapeutic modalities
I have experience working with

ChildrenAdolescentsAdultsNone
Please describe
I have experience working with

Mood disordersAnxiety disordersPersonality disordersSleep disordersNone
Please describe
Describe a challenging case your worked on and how you handled it
Why are you interested in learning Dialectical Behavior Therapy?*

Motivation and Goals
Why are you interested in Lilac Center's Fellowship Program?*
What are your professional goals and how do you see this fellowship helping to achieve them?*
Describe your core values as a person*

Introduction Video
Please upload a short introduction video with your name, why we should choose you as a Lilac Center Fellow and a personal hobby you enjoy.

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Any Additional Comments or information you would like to provide. (If you have trouble uploading video, please provide a link here for us to view)
Please click checkbox:*

I have reviewed the materials and FAQ on the website and understand that the Lilac Center Fellowship is a three-year commitment designed to provide comprehensive Dialectical Behavior Therapy training and support toward earning my clinical licensure.
Date*

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Date
Signature*

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Personal Information