Sample Application
for the
Certification Program
in Schema
Therapy
Schema Therapy Institute
Midwest
You may add additional
pages to this application to clarify or elaborate on any of the questions below,
if you need more space.
Name_________________________________________________________________
TodayŐs
Date_________________________ Gender: Male
□ Female □
Current
Institution/Organization and Title (if any):
______________________________________________________________________
______________________________________________________________________
Work Address: ________________________________________________________
City/State/Postal
Code: ___________________________________________________
Country:
______________________________________________________________
Home Address:
________________________________________________________
City/State/Postal
Code: ___________________________________________________
*Work
Telephone:
______________________________________________________
*Home
Telephone: ______________________________________________________
*Mobile
Phone: __________________________ *Fax: __________________________
Primary
E-Mail (required): _________________________________________________
Other
E-Mail address (optional): ____________________________________________
Website
(optional):_______________________________________________________
*Be sure to include your area code.
We
will generally correspond with you by e-mail. If we need to mail materials to you, which address should we
use? Work Address □ Home
Address □
I would like to apply for:
□ Standard Certification □ Intensive
Advanced Certification
I expect to complete the training program in:
□ 1 year □ 2 years □ DonŐt Know Yet
Education
& Work Experience
Highest
Degree: __________ Year Earned:
_______Field: ______________________
______________________________________________________________________
University
(Include city and country):
________________________________________
______________________________________________________________________
Describe
your Internship. Practicum Work, or Residency (including name and location of
Institutions):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Describe
any Postdoctoral Training:
______________________________________________________________________
______________________________________________________________________
Licensure/Certification:
___________________________________________________
State:
__________________________________________________________
Essential: Workshops and Training
in Schema Therapy, if any (include approximate dates, locations, hours, and
instructors):
______________________________________________________________________
List
the approximate hours per week you currently engage in the following
professional activities:
________
Direct patient contact
_______ Supervise Other Therapists
________
Conduct research _______ Other activities (please
specify):________
________
Administration
__________________________________
Main
work setting/organization: ____________________________________________
Current
Position/Title:
___________________________________________________
I
currently work with: (Rate each category on a scale from 0-3 as follows: 0 =not
at all, 1=occasionally, 2 =frequently, 3= almost always)
____
Inpatients ____
Children ____
Individuals
____
Outpatients ____
Adolescents ____
Couples
____
Partial Hospital Patients ____
Adults ____
Families
____
Criminal offenders ____
Geriatrics
____
Groups
____
Other (please specify):______________________________________________
You
may add additional pages if necessary to answer the following questions:
1.
Please elaborate on your current professional work, including training,
research, administrative and clinical activities.
2.
Please elaborate on the nature and amount of clinical training in schema
therapy you have already received.
3. Please describe your current
psychotherapy orientation in detail, including the types of patients you work
with.
4. Please elaborate on your general
clinical training and previous clinical experience.
5.
Describe your work with schema therapy, other than workshop training you
have received (e.g. articles or books you have written, number of patients you
have treated, supervisory or teaching experience, research you have
participated in).
6. After completing the Institute training
program, what kinds of professional activities do you expect to participate in related to schema therapy? (Please provide as much detail as
possible).
7. Is there any other information about
you that would be helpful to us in evaluating your application?
9. Required:
On the following page, list two professional references who have supervised or
observed your clinical work with patients. (The clinical work does not
have to involve schema therapy.)
Please ask them to forward a letter of reference directly to our
Institute.
10.
Optional: Attach the name of one other reference who can discuss non-clinical
aspects of your accomplishments (including work with schema therapy if
applicable), such as research, teaching, or administration. Please ask them to
forward a letter of reference directly to our Institute.
1st Reference:
Name: ___________________________________________________________
Position:
_________________________________________________________
Mailing
Address: __________________________________________________
________________________________________________________________
Phone:
_______________________________ Fax: _______________________
E-mail:
__________________________________________
2nd Reference:
Name: ___________________________________________________________
Position:
_________________________________________________________
Mailing
Address: ___________________________________________________
________________________________________________________________
Phone:
_______________________________ Fax: _______________________
E-mail:
__________________________________________
11.
Will you be applying for a tuition reduction or partial scholarship based on
financial need?
□ YES □ NO □
DonŐt Know Yet
Schema Therapy Institute
Midwest
Attn: Certification
Program
471 West South Street, 41C
Kalamazoo, Michigan 49007
Telephone:
269-345-8100 Fax:
269-345-8262
E-mail: training@schematherapymidwest.com