Telebehavioral Health Institute Professional Speaker Training Program Application

Thanks for your interest in our Telebehavioral Health Institute, Inc. (TBHI) Professional Speaker Training Program. It may take you up to 30 minutes to complete this application.

Please email the following information to contact@telehealth.org; Use the Subject line: Your Name - C.V. - Train the Trainer Applicant

Your C.V. in Microsoft Word format
A head shot (photo) of yourself taken within the last 3 years (10M limit)
Next, we will ask you to send three writing samples in Microsoft Word format
- If you have written a thesis, dissertation or article, please email about 20 pages of that document as your first writing sample
Your best PowerPoint or Prezi slide deck. Any topic will do. We will be reviewing your slides for layout and clarity, not content (10M limit)
Send at least two (2) audio or video recordings of your professional speaking that was recorded in the last 10 years

1. Contact Information

First Name *This question is required.

Last Name *This question is required.

Title *This question is required.

Organization *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State or Province *This question is required.

Postal Code *This question is required.

Country *This question is required.

Email Address *This question is required.

Fax Number

Office Phone Number *This question is required.

Mobile Number This question requires a valid number format.

Website

Today's Date *This question is required.

calendar

2. What is the highest level of education you have completed? (Please select at least one option.) *This question is required.

3. What is your professional area of training (clinical, educational, administrative, policy, etc.)? *This question is required.

4. Give details of all degrees or certificates you have, including year of graduation and school or facility. Name any specialized training programs you have completed. (All information provided will be verified through your educational institution.) *This question is required.

5. Have you completed the TBHI Level II Certificate program? (If you have not, completion of the TBHI Level II Program is required prior to applying to our Consultant Training. Please discontinue this application and see the program here http://telehealth.org/courses. When you have completed that training, return to this address to apply for more advanced training.) *This question is required.

Please enter an 'other' value for this selection.

6. Approximately how many hours of professional speaking have you completed in your professional life? *This question is required. This question requires a valid number format.

7. Describe the most salient details of the professional speaking events in your history. *This question is required.

8. Describe what you consider to be the greatest accomplishment in your professional speaking career so far. *This question is required.

9. How would you describe yourself? (Please select at least one choice per descriptor.) *This question is required.

Space Cell	That's Me	Sort of Me	Not Me
Outgoing	Outgoing: That's Me	Outgoing: Sort of Me	Outgoing: Not Me
Loner	Loner: That's Me	Loner: Sort of Me	Loner: Not Me
Planner	Planner: That's Me	Planner: Sort of Me	Planner: Not Me
Team mate	Team mate: That's Me	Team mate: Sort of Me	Team mate: Not Me
Organizer *This question is required	Organizer: That's Me	Organizer: Sort of Me	Organizer: Not Me
Social networker	Social networker: That's Me	Social networker: Sort of Me	Social networker: Not Me
Crowd-pleaser and "ham"	Crowd-pleaser and "ham": That's Me	Crowd-pleaser and "ham": Sort of Me	Crowd-pleaser and "ham": Not Me
Leader	Leader: That's Me	Leader: Sort of Me	Leader: Not Me
Quiet	Quiet : That's Me	Quiet : Sort of Me	Quiet : Not Me
Moody	Moody: That's Me	Moody: Sort of Me	Moody: Not Me
Spiritual	Spiritual: That's Me	Spiritual: Sort of Me	Spiritual: Not Me
Generous	Generous: That's Me	Generous: Sort of Me	Generous: Not Me
Dominant	Dominant: That's Me	Dominant: Sort of Me	Dominant: Not Me
Submissive	Submissive: That's Me	Submissive: Sort of Me	Submissive: Not Me
Avid reader	Avid reader: That's Me	Avid reader: Sort of Me	Avid reader: Not Me
Researcher	Researcher: That's Me	Researcher: Sort of Me	Researcher: Not Me
Thoughtful	Thoughtful: That's Me	Thoughtful: Sort of Me	Thoughtful: Not Me
Anxious	Anxious: That's Me	Anxious: Sort of Me	Anxious: Not Me
Designer	Designer: That's Me	Designer: Sort of Me	Designer: Not Me
Artist	Artist: That's Me	Artist: Sort of Me	Artist: Not Me

10. Name the top 3 skills you'd most prefer to contribute to TBHI as part of this Training program. *This question is required.

11. What are the top 5 personal attributes that you bring to our Institute? *This question is required.

12. Describe any other special skills or personality attributes that you want us to consider. *This question is required.

13. Please don't tell us the name, but think of one colleague who always gave you energy. Tell us about him or her and what worked so well for you? *This question is required.

14. How did you learn of the TBHI Professional Speaker Training Program? *This question is required.

15. Why are you interested in our Institute? *This question is required.

16. What about the TBHI Professional Speaking training program excites you the most? *This question is required.

17. In applying to be a TBH Professional Speaker, are you willing and able to travel to participate in at least two of Dr. Maheu's full day workshops at your own expense as part of your TBHI Speaker training? *This question is required.

Please enter an 'other' value for this selection.

18. Will you be you able to travel to San Diego to participate in a Train-the-Trainer or Train-the-Consultant program? *This question is required.

Please enter an 'other' value for this selection.

19. How many hours per week are you available to conducting Internet or other research related to your TBHI Speaker Training? *This question is required. This question requires a valid number format.

20. If you have a financial need compelling your application for financial assistance, please describe it below. (Proof of financial need will be required if you are selected.) *This question is required.

21. Provide the names and email addresses of three references for us to contact to ask about your work performance and character. *This question is required.

22. Have you ever been convicted of a felony or lost your license? Do you have any pending charges against you or your license? If yes to either or both questions, please give details (what, where, when)? *This question is required.

23. I attest that the answers above are true. *This question is required.

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Signature of

Telebehavioral Health Institute Professional Speaker Training Program Application

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