Fillable FAMILY-BASED THERAPY EXAMINATION APPLICATION (Pennsylvania Certification Board)

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FAMILY-BASED THERAPY EXAMINATION APPLICATION (Pennsylvania Certification Board)

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The FAMILY-BASED THERAPY EXAMINATION APPLICATION (Pennsylvania Certification Board) form is 3 pages long and contains:

  • 1 signature
  • 21 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

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PCB FBT Examination Application | Revised February 2021
1
FAMILY-BASED THERAPY EXAMINATION APPLICATION
DIRECTIONS/CHECKLIST – READ DIRECTIONS CAREFULLY
Prior to submitting your application to PCB, please review the following list to be sure you have included all the
necessary documentation.
1. Documentation of graduation from an approved Family-Based Therapy (FBT) training organization. The training
organization must provide you a letter or certificate of completion to include with your application that includes
the name of the training center and the beginning and completion date of the training.
2. Complete page 2 (Program Director signature is required).
3. Complete the payment page (page 3). If your agency is paying for your examination, please indicate that on the
payment page. Applications will not be approved without payment.
4. Complete and return ONLY pages 2 and 3 and include the letter or certificate from the training organization.
• DO NOT submit your application until you have met ALL requirements.
• If there are any problems with the application, you will be notified by email.
• Keep a photocopy of the entire application for your records.
• Applications can be mailed, emailed, or faxed. Please use only ONE method to submit your application.
EXAMINATION OVERVIEW
The successful completion of the PCB family-based therapy examination is required.
There are two options for taking the examination: an on-demand computer-based examination or a paper/pencil
examination given regionally in Pennsylvania on limited dates/locations.
The examination consists of 75 multiple-choice questions. Once an application is approved, candidates will receive an
email from PCB with instructions for choosing the format to take the examination.
One and a half (1.5) hours is the time permitted to complete the exam. The examination is based on the Content Outline
developed in 2018. This document is available on the PCB website at www.pacertboard.org/FBT
.
PCB FBT Examination Application | Revised February 2021
2
PCB APPLICATION FOR FBT EXAMINATION
Please type or print only.
Date:
Date of Birth:
□ Female □ Male
□ Self-identify: _______________________
Home Address:
City:
State:
Zip:
Cell Phone:
Email:
(REQUIRED)
Employer:
Position/Title:
Employer City:
Employer Zip:
Work Phone:
Ext:
Training Center:
□ Center for Family Based Training
□ Philadelphia Child and Family Therapy Training Center
□ UPMC Western Psychiatric Hospital (formerly WPIC)
Training City:
Highest level of education completed: □ Bachelor’s degree □ Master’s degree □ Doctoral degree
Ethnicity: □ American Indian or Alaska Native □ Asian □ Black or African American □ Caucasian □ Hispanic □ Latino
□ Native Hawaiian or Other Pacific Islander □ Not specified: ______________________
PROGRAM DIRECTOR RECOMMENDATION
By signing below, I am recommending the above applicant to take the Family-Based Therapy examination. I also
understand that the fee for the examination is $75 and the applicant will not be able to take their examination until the
fee is paid to PCB.
Program Director Name:
(please print)
Program Director Signature:
Date:
click to sign
signature
click to edit
PCB FBT Examination Application | Revised February 2021
3
PAYMENT INFORMATION
FEE OF $75 CAN BE PAID USING ONE OF THE FOLLOWING (CHECK ONE):
□ Personal Check □ Organization Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB.
NOTE: If your organization is paying for your application and payment is not included, you will be unable to take the
examination until payment is made. Please be sure that your organization indicates what their payment is for and for
whom if they are sending it separately.
Email for receipt (if paying by credit card only): ________________________________________________________________
TO SUBMIT YOUR APPLICATION, CHOOSE ONLY ONE OF THE FOLLOWING METHODS:
Mail:
PCB
298 S. Progress Avenue
Harrisburg, PA 17109
Email:
info@pacertboard.org
Fax:
717-540-4458
Please allow up to 5-10 business days for review and processing of your application.
To confirm receipt of your application or check on the status, you must email info@pacertboard.org.
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
(If different than Home Address)
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FAMILY-BASED THERAPY EXAMINATION APPLICATION (Pennsylvania Certification Board)

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Completed 3 June 2021

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