Please provide the following information and affirmations so that we have all the information we need to review your eligibility and provide you with more information and materials if you are selected.

Thank you for taking the time to complete this application. Your application will be reviewed, and you will be contacted with next steps.  
 
In the meantime, if you have any questions, please contact: Utah Tic Lab by phone at 801-585-7114 or by email at theticlab@utah.edu.

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* 1. First Name

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* 2. Last Name

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* 3. Phone 

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* 4. Email Address

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* 5. Street Address

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* 6. City

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* 7. State

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* 8. Zip Code

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* 11. I am willing to be randomly assigned to virtual or in person training conditions.

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* 12. I am willing, able, and have the necessary resources to travel to, and attend, one of several in- person training sites if assigned to the in-person training condition.

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* 13. I have the equivalent of a master's degree or higher in a mental/behavioral health, medical, or related discipline.

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* 14. I possess a professional license and/or certification to practice in my specific area of specialty.

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* 15. I attest that providing CBIT to treat children and/or adults with tic disorders falls within my scope of practice according to state licensing laws and regulations in my jurisdiction.

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* 16. I have access to a secure personal computer with high-speed internet access.

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* 17. I speak fluent English.

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* 18. I either have access to A) at least 1 child or adult patient or B) am willing to find a child or adult patient, who has a tic disorder and who is willing to participate in the study as a member of the therapist-patient dyad, and for whom the therapist is licensed or certified to treat with CBIT according to state licensing laws and regulations in their jurisdiction.

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* 19. I understand that the patient identified to serve as my training case cannot be my first, second, or third degree relative; stepchild; or legal ward.

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