CTI Application for Admission

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CTI Application for Admission

March 4, 2010 - 1:34pm — gfermin

2011-2012 Child Trauma Training Institute (CTI)

Program Cost $1,500

Please submit these materials to complete your application:
This form will require 30 minutes to complete.

This application form (apply here and submit)
A letter of reference from your primary clinical supervisor (mail)
The sponsorship agreement from your agency's executive director or clinical director (mail) Click here for form.
Your resume (mail or email)

Mailing Address: Parents Place, Koret Family Resource Center Child Trauma Training Institute, 1710 Scott Street, San Francisco, CA 94115; Attention: Rod Wood

Email: RodW@jfcs.org

See information aboout our "Capacity-Building Option" for agencies. Tuition for this option is $1,200, a savings of $300 per participant.

Personal Data

Name: *

Phone: * (xxx)xxx-xxxx

Mobile #: * (xxx)xxx-xxxx

Email:

If other, please list:

If other, please list

License type & number: (e.g., MFT-12345)

CTI training will take place at our San Francisco location. A limited number of spaces are available through our web-based long distance option for participants who are unable commute to our location.

Are you applying for our distance learning option?:

Yes

Are you applying as a Clinical Supervisor?:

Yes

Have you attended a previous CTI training year?:

Yes

Are you applying for a scholarship:

Yes

Agency or Practice Information

If other, please list:

Agency

Name:

Address:

Phone: (xxx)xxx-xxxx

Fax: (xxx)xxx-xxxx

Executive Director

Name:

Email:

Phone: (xxx)xxx-xxxx

Clinical Supervisor

Name:

Email:

Phone: (xxx)xxx-xxxx

Your Position at Agency:

Previous Training and Experience

Describe your work experience with young children from birth through age five. If you have had any early childhood mental health work experience, please describe:

Have you had any previous training in early childhood mental health? If so, please describe:

Have you had any previous training in trauma treatment? If so, please describe:

How will this training benefit you, your agency, and families you serve?:

Estimate the PERCENT of your time in a typical workweek spent serving or performing activities for children of the following age or their parents

Birth - 1 year:

1 year - 2 years:

2 years - 3 years:

3 years - 4 years:

4 years - 5 years:

Other:

How did you hear about CTI?:

September 2011 - May 2012: $1,500

Scholarships may be available

We look forward to your participation in this program, a collaboration of:

Jewish Family and Children's Services

Parents Place

UCSF/San Francisco General Hospital/Child Trauma Research Program

Support for the Child Trauma Training Institute is provided by fees, corporate and individual donations, and major grants from the John and Lisa Pritzker Fund and the Ingrid D. Tauber Philanthropic Fund.