temp - Ghost Mothers

Email address
Date Application Completed	First Name	Last Name

Professional License Information

How long have you held this license?

Name and credentials as you would like it to appear on your ISST certificate?

Name you prefer to be called:

Current clinical treatment setting:	Practice Name
Your position or title:	Primary population treated:

What is your current psychotherapy orientation?

PRACTICE INFORMATION:

Street Address:	City	State
ZIP	Country

Practice Phone

Website

PERSONAL INFORMATION:

Street Address	City	State
ZIP	Country

Are you applying for Standard or Advanced Certification?
Standard Advanced Facilitate Schema Therapy

NOTE THE FOLLOWING:

1. Complete all pages on this Application Form, and submit the documentation requested. We want to remind you there are a limited number of spaces available. Submission of this application does not guarantee you a place in the training.

**APPLICATIONS ARE REVIEWED upon receipt of all information requested. You will be directly notified (via the email provided) as to whether you have been accepted.

2. The following supporting documentation MUST be included as part of your application; it will not be reviewed until we receive all listed below:

● Up to date Resume or Curriculum Vitae

● Copy of professional licensure or certification

● 2 letters of recommendation, on letterhead, from mental health professionals who know your clinical work, and support your application to learn Schema Therapy; have these sent directly by the professional to: krudlinlcsw@att.net

LIST the 2 professionals providing recommendations on your behalf:

Please answer each question completely:

1. This is an experiential learning program. Describe your access to treat personality disordered clients, clients with significant PD features, or clients who will benefit from schema therapy and schema mode work (due to complication, chronicity, failure to respond to treatment, or relapse) during the time you’re training in schema therapy.

2. Describe your interest in schema therapy, and your goals in pursuing education and skills in this therapeutic approach. What is your primary motivation to become a certified Schema Therapist? How will becoming certified, or taking the training, help meet your goals as a therapist?

3. LIST all schema therapy training, experience, and/or supervision you’ve already received. Include books or articles on schema therapy you have studied. Include approximate dates, location, trainers, as applicable. What about ST inspires you to learn more? List the reasons you are drawn to this approach/model.

4. An essential element of the certification program requires your individual supervisor review recorded therapy sessions with your clients. How will you arrange this and is it agreeable to your organization/employer? (Written agreement from clients is required.)

5. Academic training: you must hold a minimum of a Master’s degree in a field of mental health, or the equivalent. Provide details below, to include dates and the institution where you earned your degree. (List all relevant upper-level degrees, and where you did your internship, residency or practicum)

6. Accreditation for clinical practice: you must be licensed or accredited with one of the regulatory bodies in the field of mental health. Please provide all details, to include dates and membership numbers.

7. ISST regulations stipulate completing the full certification process within 3 years after completing the workshop components of the program. (Note: extensions can be granted in extenuating circumstances.) Can you commit to this timeframe? What schema related activities do you plan to pursue after completing your schema training/certification?

8. Discuss your current work as a mental health professional, and how schema therapy will add value and enhance the conceptualization and strategies you are currently using. Be specific based on what you currently know about the ST model.

9. Please add anything else you wish to include to express your interest in ST and support your application.

WE WELCOME your application at any time prior to the deadline. We will note when the current training program is full. You will receive a follow-up email confirming we have received your submission.