ISST Application Form for Certification 20121 Page 1
Application Form for Certification 2023
IMPORTANT: To fill this form correctly please read carefully the instructions at
the end of the document and type your responses into empty boxes next to each item.
Your responses should be typed in the appropriate boxes and not handwritten.
1. APPLICANT’S DATA
Name
(as you want it on your
certificate):
Applying for:
Child-
Individual Group Couples Auxiliary
Specialty Area Adolescent
Standard Advanced Trainer Supervisor
Certification Level
Membership ISST Membership
Date joined ISST
ISST Membership Type Number
Email Address:
Country:
Academic Degree Discipline/subject Year awarded
Credentials *
Licensed as a Date of renewal / expiration
Type of License and Number:
Psychotherapist if applicable:
according to ISST
definition
If your country does not issue licenses,
insert here the name of the national
professional organization you are
registered with:
If you are already Certified in one of the
Schema Therapy Specialties please
indicate the specialty type and level of
Certificate, its number and date of issue:
ISST Application Form for Certification 20121 Page 2
2. TRAINING COMPONENT
Date ST Training Started Date ST Training Completed
List the modules or the full program you attended and attach copies of the certificates:
Hours Number of Trainer’s
Workshop Name Subject(s) covered Dates
Didactic Role-play participants Names
Total hours - Didactic / Role-play
3. SUPERVISION
Hours (converted to Date Date
Supervisor Name
individual hours) started completed
Total hours (converted to individual
hours – see converting widget on the
ISST website)
4. TREATMENT HOURS AND NUMBER OF CASES
Patients Initials Number of sessions Diagnosis(es) Or modes
ISST Application Form for Certification 20121 Page 3
5. EVALUATION OF SESSIONS RECORDINGS AND CASE CONCEPTUALIZATIONS
Name of Rater STCRS STCCRS Date of Rating Diagnosis(es) or
Score Score Modes
I herewith confirm that all statements on the application are accurate and I agree to abide by
the requirements and conditions of ISST certification at the level I am granted. I understand
that I must be a full member of ISST, continue education and training in ST and pay annual
membership fees on time to maintain my status as an ISST certified schema therapist.
Date: Signature:
List of attachments. Please fill the following table and check if you attached all necessary
copies of documents to support your Application.
# Item Attached (V) Number of pages
1 Diplomas & Degrees
2 Licenses
3 ISST Workshop Certificates
(Acknowledgements)
4 Supervisor(s) confirmations
5 Rating Summaries
6 Letters of extensions granted
7
Total pages:
Please email this form and Checklist and copies of your degree(s)/certificates and other
relevant documents (see section 1 in Instruction Guide) to the reviewer (coordinator) listed for
your country or region on the ISST website [Link] on Certification
page
ISST Application Form for Certification 20121 Page 4
Attachment 1
Instruction Guide
for ISST Schema Therapy Certification Application Form
IMPORTANT:
1. Please save Application files as
first name_last name_ Application_level of certificate_specialty.pdf
Example: Dean_Reed_application_standard_individual.pdf
2. Please save Checklist files as
first name_last name_ checklist_level of certificate_specialty. doc (or .docx)
Example: Lean_Green_checklist_standard_group.doc (or .docx)
1. APPLICANT’S DATA
Full membership of ISST is a requirement if applying for ISST certification. Your
membership number and date you joined the ISST should be provided in the
appropriate boxes.
Tick or mark “X” in appropriate boxes to specify Specialty Area and Level of
Certification you are applying for.
Membership
To qualify for Standard or Advanced level certification in Schema Therapy
(other than Auxiliary Professional Certification – see requirements on the ISST
website) a person must fulfill the following two qualifications:
1. Academic training: Hold at least a master's degree in psychology, clinical social work,
psychiatric nursing or a counseling area that leads to licensing; or a medical degree
with psychiatric residency (or residency equivalent if it is defined differently in your
country).
2. License or certification for practice: In countries that certify or license the above
professions, a person must be certified or licensed by either the government body or
recognized professional organization, which grants this. If no such control exists in a
country, the standard of one of the national or international professional
psychotherapy organizations must be met to fulfill this requirement.
If you belong to another group that is licensed or certified to practice psychotherapy
in your country, please submit this information with your academic qualifications
before applying to be considered for ISST certification. If your country has a specific
qualification it must be met (e.g. UK)
Please attach copies of your degree(s), diplomas, licenses, certificates and other relevant
documents in support of the qualifications mentioned above.
N/a
If you have any doubt as to whether you meet any of the qualifications, ask the Certification
Coordinator for a review before applying for certification.
2. TRAINING COMPONENT
3 years
Please write the date when you attended the first certification training
workshop/module and the date when you completed the required curriculum. (Workshops or
ISST Application Form for Certification 20121 Page 5
lectures that are not part of an ISST approved certification training program do not count as
the date you began.) Only ISST approved Certification training program sessions count
towards Certification.
In the table please list and describe the modules or identify the full certification
program you attended. All necessary information should be found in the Certificate
(Acknowledgement) you received on completion of a particular module or the whole program.
Please attach a Certificate (Acknowledgement) of completion for each workshop or module,
which must include: signatures of the ISST Certified Trainers/Supervisors and Director of the
ISST Approved Training Program, name of the ISST Approved Training Program and the
date of its approval.
Make sure you meet minimum hours’ requirement according to your specialization
both in didactic and dyadic/practice/role-plays parts of the curriculum as it is described on the
ISST website.
Please list only courses relevant to the specialization you are applying for (e.g.,
Individual, Group).
Certificates must be issued by the certified Training Programs. All Trainers and
Supervisors must be ISST certified Trainers/Supervisors, affiliated with the approved training
program and be active members of ISST (i.e. membership fees are current).
Important: For the dyadic/practice/role-plays part of the curriculum the maximum is 20
participants per one trainer. !2 didactic hours may take place in a group of more than 20.
3. SUPERVISION
Supervisors are required to send a brief letter of confirmation by email of the
supervision hours and the number of patients that were treated during supervision directly to
the Certification Reviewer for the region in which you practice and copy.
All hours in the table must be converted individual hours if group supervisions took
place. You can find the formula for making the conversion on the ISST website.
There is a minimum of 1 year and maximum of 3 years to fulfill the supervision
requirements and rating(s) of recordings/videos, once training is completed. Requests for
exceptions for special circumstances, i.e., health, financial, family crises, etc., that require
extensions on supervision time, must be submitted to the ISST Training Coordinator before
application. Please apply for such exceptions well in advance of your application, so it’s not
last minute in case you do not qualify for the ISST definition of allowed exceptions.
Supervisors must be ISST approved, advance level certified supervisor-trainers in the
specialty area you are applying for. They must be current in payment of membership fees,
and completion of the Continuing Education requirement at the time they provided
supervision or training for you. This should be checked by you by consulting the ISST website
listing of supervisor-trainers [Link].
4. TREATMENT HOURS AND NUMBER OF CASES
Total amount of treatment hours/diagnoses must be in compliance with the certification
requirements in the specialization you are applying for.
I.e. in Individual ST:
Standard certification - at least 2 cases of minimum 25 sessions and 80 sessions in
total. One patient with a personality disorder or significant personality disorder features and
one patient who is appropriate for Schema Mode work due to complication, chronicity, failure
to respond to treatment or relapse.) For specialty certifications consult the requirements
listed.
ISST Application Form for Certification 20121 Page 6
Advanced certification — at least 4 cases of minimum 25 sessions and 160 sessions
in total (One patient with a personality disorder or significant personality disorder features
and the remainder patients who are appropriate for Schema Mode work due to complication,
chronicity, failure to respond to treatment or relapse.) For specialty certifications consult the
requirements listed.
5. COMPETENCY RATING SCALE
The rater(s) must be an independent supervisor (not the trainer or training supervisor),
preferably one who does not know the applicant well
STCRS Score - Schema Therapist Competency Scale rating result
STCCRS Score - Schema Therapy Case Conceptualization Rating Scale rating result
The rater must send confirmation of the scores, along with the summary sheet from
the STCRS form and the completed STCCRS form by email directly to the regional
representative. The audio or video recording must show a whole therapy session.
Standard certification requires a score of 4.0 or higher. Advanced certification requires
a score of 4.5 or higher on both recordings. For the Advanced level, one recording must
demonstrate competence with the Avoidant/Surrender Coping modes and the other with the
Overcompensating Coping modes. For Standard certification either style is acceptable.
A case conceptualization form must accompany each session to be rated, along with
the session summary form for the session to be rated.
The completed Application form must be signed by the applicant. Scan the signature
page or use facsimile signature and attach it to the PDF file. The whole application must be in
a single file.
Complete the Checklist and save as Word file.
Application, Checklist and all other required documents must be sent to your regional
certification coordinator.