Schema Therapy Institute Midwest

2012 Application for the

Certification Program

in Schema Therapy

All applications and supporting materials for the 2012 program

must be received by December 16, 2011.

You may add additional pages to this application to clarify or elaborate on any of the questions below, if you need more space.

Name____________________________________________________________________________________

Today’s Date_________________________ Gender: Male □ Female □

Current Institution/Organization and Title (if any):

_________________________________________________________________________________________

Work Address: ___________________________________________________________________________

City/State/Postal Code: ______________________________________________________________________

Country: _________________________________________________________________________________

Home Address: ___________________________________________________________________________

City/State/Postal Code: ______________________________________________________________________

Country: _________________________________________________________________________________

*Work Telephone: _________________________________________________________________________

*Home Telephone: _________________________________________________________________________

*Mobile Phone: _______________________________________ *Fax: ________________________________

Primary E-Mail (required): ___________________________________________________________________

Alternate E-Mail address (optional): __________________________________________________________

Website (optional):_________________________________________________________________________

*Be sure to include your area code.

If we need to contact you by telephone from 9am to 4pm, Eastern Standard Time time, which number(s) should we use?

Work Phone □ Home Phone □ Mobile Phone □

I expect to complete the training program in:

□ 1 year □ 2 years □ Don’t Know Yet

Education & Work Experience

Highest Degree: _____________ Year Earned: __________Field: ____________________________________

If you are applying from outside the US, please explain the degree(s) you have obtained, and the exact field of study. (Please explain how many years of study are involved, and whether your degree is closest to a bachelor’s, Master’s, or doctorate degree in the US.)

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

University (Include city and country): _________________________________________________________

_________________________________________________________________________________________

Describe your Internship. Practicum Work, or Residency (including name and location of Institutions):

________________________________________________________________________________________

Describe any Postdoctoral Training:

_______________________________________________________________________________________

Licensure/Certification, (if required in your country): ____________________________________________

_______________________________________________________________________________________

State/Country: ___________________________________________________________________________

Essential: List previous workshops and training in Schema Therapy, if any (include approximate dates, locations, hours, and instructors; add additional page if necessary):

List the approximate hours per week you currently engage in the following professional activities:

________ Direct patient contact _______ Supervise Other Therapists

________ Administration _______ Take courses; study

________ Research _______ Other activities (please specify):_____________________

_______________________________________________________

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?

8. 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, but ST is preferred.) Please ask them to forward a letter of reference directly to us at: training@schematherapymidwest.com

10. Optional: Attach the name(s) of one or more other references 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 at: training@schematherapymidwest.com

1^st Clinical Reference:

Name: _____________________________________________________________________________

Position: ____________________________________________________________________________

Mailing Address: ______________________________________________________________________

___________________________________________________________________________________

Phone: _______________________________________ Fax: __________________________________

E-mail: ______________________________________________________________________________

2^nd Clinical 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 □ Don’t Know Yet

You can send us your completed application by email (as a Word attachment); by fax; or by regular mail. Our contact information is:

Schema Therapy Institute Midwest

Attn: Certification Program

471 West South Street, Suite 41C

Kalamazoo, MI 49007

Telephone: 1-269-345-8100 Fax: 1-229-345-8262

E-mail: training@schematherapymidwest.com