Dance/Movement Therapy Certification Board, Inc

1

DMTCB

DANCE/MOVEMENT THERAPY CERTIFICATION BOARD, INC.

10632 Little Patuxent Parkway, Suite 108, Columbia, MD 21044

APPLICATION FOR REGISTERED DANCE/MOVEMENT THERAPIST

Alternate Route and Other Dance/Movement Therapy Program

Before completing this application, thoroughly read and follow the

"Applicant Handbook Registered Dance/Movement Therapist (R-DMT)"

DIRECTIONS:

• Click once on the gray-shaded, underlined area and fill in required information.
• Please check boxes so that an X appears.

Upon completion,mail or email to:
DANCE/MOVEMENT THERAPY CERTIFICATION BOARD

10632 Little Patuxent Parkway, Suite 108
Columbia MD,

All information supplied by applicant will be regarded as confidential in natureand will not be released to third persons without the consent of the applicant. Application may be used as training material by DMTCB.

Check here for application type:

Alternate Route

Other Dance/Movement Therapy Program

If Other Dance/MovementTherapy Program, you must submit a letter of sequencing from yourGraduate program. See Applicant Handbook for more.

NAME:

BIRTHDATE:

ADDRESS:

CITY, STATE: ZIP CODE:

COUNTRY:

HOME PHONE: WORK PHONE:

E-MAIL:

MASTERS DEGREE TITLE:

FROM (School): MASTERS DEGREE DATE:

1. COURSEWORK

All support documentation required (other than official university transcript) must accompany this application in quadruplicate. See Applicant Handbook for full details. Each course can only be listed once for credit toward one requirement.

A.DANCE/MOVEMENT THERAPY TRAINING

1.Dance Therapy Theory and Practice

Alternate Route - 270 hours or 18 credits

Other Dance/Movement Therapy Program – 225 hours or 15 credits over A1 & A2

1. Group Processes in Dance Therapy

Alternate Route – 45 hours or 3 Credits

Other Dance/Movement Therapy Program – 15 Credits over A1 & A2

1. Movement Observation and Assessment

90 hours or 6 Credits (May be taken as independent study)

1. Anatomy and Kinesiology

45 hours or 3 Credits (May be taken as a prerequisite on the undergraduate level)

1. GENERAL TRAINING

1. Research Design and Methodology

45 hours or 3 Credits

1. Abnormal Psychology/Psychopathology

45 hours or 3 credits

1. Developmental Psychology

45 hours or 3 Credits

1. Group Processes/Dynamics

45 hours or 3 Credits

1. Advanced Counseling/Psychology Courses

Minimum of (2) 45 hour or 3 credit courses

Methods of Psychotherapy/Counseling

Theories of Therapy/Counseling

Therapeutic Intervention

Diagnostic Methodology

Systems Theory

Neuroscience

1. FIELDWORK (Practicum)

3 Months full-time or its equivalent in part-time to total 200 hours

If you have more than one fieldwork site, please make additional copies of this page for each site and attach. Field placement may be waived for applicants with transcripts verifying Internship placement in another mental health field.

Clinical Setting:

Dates: From To

Total number of hours (200 hours required, see Procedural Information):

Name and Address of Clinical Supervisor:

Brief Description of your responsibilities in placement:

1. DANCE THERAPY INTERNSHIP

A minimum of two (2) populations - include only internships supervisedby a BC-DMT.

SEND A VERIFICATION FORM TO YOUR SUPERVISOR. IF YOU HAVE MORE THAN ONE INTERNSHIP SITE, SEND VERIFICATION FORM TO EACH AND MAKE ADDITIONAL COPIES OF THIS FORM FOR EACH SITE AND ATTACH TO APPLICATION.

Clinical Setting:

Dates:FromTo:

# Weeks: Number of hours per week:

Total hours (700 required):

Total hours of Direct Patient Contact (350 hours required):

Total hours of Leading DanceTherapy Sessions (150 hours required):

Total hours of Other Clinical Responsibility:

Total hours of On-Site BC-DMT supervision at this site (10 hours required):

Total hours of BC-DMT supervision (70 hours required, 24 hours must be with same supervisor):

Populations (minimum of two):

Name and Address of clinical BC-DMT supervisor:

1. TRAINING

1. DANCE TRAINING

Five years concentrated study and practice leading to competence in at least one traditional dance form such as modern, ballet, jazz, tap, folk or ethnic.

1. COLLATERAL DANCE STUDIES

Such as dance theory, dance composition, creative dance,improvisation, etc.

1. MOVEMENT STUDIES

The required dance training can be supported by movement studies such as Yoga, Alexander Technique, Tai-Chi, etc. DMTCB does not accept these as substitutionfordance training.

1. DANCE EXPERIENCE

1. TEACHING

1. EDUCATION:

Please have official transcripts from all schools listed, sent directly from the school to the DMTCB in a timely manner.

1. Dance Therapy Graduate Degree Program:

Dates(from – to):

Degree Earned:

OR

1. Graduate Degree Program other than dance/movement therapy:

Dates: (from-to):

Degree Earned:

Degree in:

1. Undergraduate Institution:

Dates (from – to):

Degree Earned:

Major: Minor:

1. List state of other professional licenses, diplomas, certificates including type of license, licensenumber and original date of issue.

1. RECOMMENDATIONS:

Please list the name and address of two (2) BC-DMTs who haveseen your work within the last two years, and have agreed to write letters of recommendation for you. If it is difficult to have two BC-DMTs write letters foryou, you may substitute one (1) from a mental health professional who has recently seenyour work.

1. Name: Title:

Address: City & State:

Zip Code:

E-mail:

1. Name: Title:

Address: City & State:

Zip Code:

E-mail:

1. PLEASE ANSWER THE FOLLOWING QUESTIONS

1. Has any claim or suit for alleged violations of the ADTA Code of Ethical Practice ever been brought against you?

NoYes

1. Have you ever been subject to disciplinary action?

NoYes

1. THE FOLLOWING IS TO BE SIGNED UNDER OATH

I,(Enter Name)have read and agree to support and Abide by the American Dance Therapy Association’s Code of Ethics and Standardsof Practice. In recognition of the responsibility of the R-DMT to the general public, I affirm under oath that information submitted to Dance/Movement Therapy Certification Board is correct in all material ways and that misrepresentation of a material nature or omission of a material nature shall render this application null and void. Ifurther agree to abide by the decision(s) of the Dance/Movement Therapy Certification Board as specified in the Applicant Handbook without recourse to legal action.

______

Applicant’s Signature

Subscribed to and sworn before me this(Enter Day)day of(Enter Month), year (Enter Year)

______

Notary Public’s Signature

My commission expires:(Enter Month, Day, Year)

$150.00 non-refundable application fee enclosed

Check here if you have previously applied for the R-DMT.

If so, please give date(s) (Enter Month, Day, Year)

R-DMT Alternate Route or Other DMT Program Checklist

Applicant: ______

THE FOLLOWING REQUIREMENTS MUST BE MET IN ORDER FOR YOUR APPLICATION

TO BE REVIEWED BY THE DMTCB. APPLICATIONS IN WHICH REQUIREMENTS

ARE NOT MET WILL BE REJECTED.

FOR OFFICE USE ONLY:

Application #: ______

Notification of missing materials sent:______Received:______

DATEDATE