DBT CITI 2024-2025 Application

"*" indicates required fields

Are you applying as an Individual Clinician or a DBT Team?*

If you are applying as a team, make sure that each of your team members submits an individual application.

Individual Clinician

DBT Team

Individual Application

Select all that apply*

Private Practice that utilizes DBT Treatment

Private Practice that does NOT currently utilize DBT Treatment

Currently employed at an agency or facility that utilizes DBT treatment

Currently employed at an agency or facility that does NOT currently utilize DBT treatment

Current member of a DBT team

Other (please specify)

If you selected "other" please specify here:

Name of your Agency/Facility or DBT Team*

Legal Name*

First Last Licensure

Chosen Name & Pronouns (if applicable)

First Pronouns

Phone*

Email*

Year Graduated from Graduate School

Job Title

Psychologist

Social Worker

Counselor

Nurse

Psychiatrist

Occupational/Vocational Therapist

Other

Other Job Title

Theoretical orientation(s) of your training

May we add you to our email list?

Information will not be shared with third parties

Yes, please

No, thank you

Level of Participation*

DBT CITI Part I Only: Intended only for members of existing DBT programs who will be returning to an intact DBT team who can support their learning and practice of DBT.

DBT CITI Part I and II: For existing DBT teams and programs who wish to strengthen core competencies and refine program direction. DBT CITI Part I and II is also intended for newly established DBT programs striving for adherence, with an emphasis on program development and implementation in various settings.

If applying for Part I Only, please provide the name and contact info of your current team lead:

Previous DBT Training and Experience

Please describe any DBT consultation(s) you have received.

Please describe the DBT intervention(s) that you have conducted yourself.

Please give a brief description of your experience learning and applying behavioral therapy.

Please give a brief description of your experience practicing mindfulness, mindfulness based practices, and/or delivering mindfulness based therapies

In your current or past clinical work, have you taught behavioral skills and/or psycho-educational materials to clients?

If yes, please give a clinical example.

Are you currently or do you plan to be on a DBT consultation team in the foreseeable future? (If not, CITI may not be the most appropriate training as it is intended for practitioners delivering or seeking to deliver adherent DBT as part of a team. Please reach out to training@pdbti.org with questions)

Yes

How did you hear about us?*

If you selected "other," please specify

Additional Comments

Scheduling

The intensive training lasts from 8:30 am to 4:00 pm Pacific Time each day, and on some evenings there will be homework assignments. In addition, it will not be possible to answer phone calls during the training or leave for other job responsibilities. Arrangements need to be made to meet these requirements. Will you arrange:

Coverage of outside responsibilities so you can come at 8:30 am, stay until 4:00 pm, and do up to 30 min of homework on some evenings?

Yes

Coverage for your work so you will not have to leave or take calls during the training?

Yes

CITI Planning and Development

People have a lot of reasons to learn DBT – from an inherent interest in the treatment, borderline personality disorder, or suicide to a desire to reduce burnout, meet expectations of supervisors, or try something new. The following questions are designed to help plan the training and will not be used as a basis for your acceptance. There are no right or wrong answers!

What are your primary and personal goals for learning DBT?

Do you foresee problems that may interfere with your participation in completing the DBT CITI training?

What plans do you have to overcome the aforementioned problems? Please also indicate whether you have discussed these potential barriers with your team.

Additional Comments

DBT Team

Agency / DBT team name*

Name of person submitting the CITI team application*

First Last

Job Title

Phone

Email*

CITI Team members

Number of CITI DBT team members.*

DBT Team Leader*

First Last

DBT Team Leader Phone

DBT Team Leader Email*

CITI DBT Team Leader

If your DBT team leader will NOT be present for DBT CITI, please name a team member who will act as DBT team leader for the purposes of this training.

First Last

Please list the first name, last name, licensure, and email address of each of your team members.*

Please add additional team members using the plus sign to the right of the email address column. If you do not yet know the team members who will be participating, please enter “Unknown” under first name.

First name

Last name

Licensure

Email address

Tell us about your team.

Level of Participation*

DBT CITI Part I Only: This is intended for members of existing DBT programs who will be returning to an intact DBT team who can support their learning and practice of DBT.

Please give a brief description of the treatments provided at your treatment facility (individual psychotherapy, case management, pharmacotherapy…)

In a nutshell, describe your team and indicate your team’s goals with respect to building a DBT program.

Comments or questions

How did you hear about us?*

Tell us about yourself

Please give a brief description of the treatments you provide (individual psychotherapy, case management, pharmacotherapy…)

In a nutshell, describe yourelf and indicate your goals with respect to participating in DBT CITI.

Comments or questions

Invoicing

Name of the person responsible for processing invoices.

First Last

Email where invoice is to be sent.

Invoicing Phone

Invoicing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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DBT CITI 2024-2025 Application

Individual Application

Scheduling

CITI Planning and Development

DBT Team

CITI Team members

Tell us about your team.

Tell us about yourself

Invoicing

DBT Training Calendar

News & Updates

Join the PDBTI team!

DBT CITI Part I 2024 Dates Announced!

Training Scholarships Now Available!

Resources While You Wait

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