Application for Remote Advanced ESDM Workshop South Shore Psychological Services, INC

Please supply all requested information; a complete application is required for full consideration. 

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NAME OF APPLICANT *
What are the dates of the workshop you wish to attend? *
Applicant's Work Setting and Work Address:  *
Professional Job Title *
Email: *
Phone number: *
Mailing Address: *
Highest Earned Degree and Certifications *
Number of Direct Therapy/Treatment Hours you Provide per week *
Age range of most children with whom you work *
Required
Describe your core program/service details relative to young children diagnosed with an Autism Spectrum Disorder (ASD) or at risk for ASD. *
Why do you want to participate in this training program? *
By typing my name below you acknowledge that, if successful in being selected for training workshop, you:
     *have completed or are scheduled to complete the Introductory ESDM workshop prior to participation in the Advanced Workshop
     *work regularly with 12-60 month old children with ASD
     *Have an educational degree beyond a Bachelor's degree (e.g. MA, Ph.D., BCBA, MFT, SLP, OT)
     *Have purchased, read and will use a copy of the manual "Early Start Denver Model for Children with Autism: Promoting Language, Learning, and Engagement" and the "Early Start Denver Model Curriculum Checklist" (Sold separately ) during this workshop.
     
     *Understand that the cost of the workshop is $2000 per participant

A workshop will include between 3 and 5 participants 
 *
I would like to apply to complete supervision toward certification as an ESDM Therapist.  This process involves completion of three submissions of materials, including written programs, collected data and video recordings of my work implementing ESDM with children with ASD.  The process takes on average between 8 months and a year to complete.  The cost is $1500 for supervision and coaching to prepare the submissions.
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Date of application *
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