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Contact Us Roster Applications

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STATEWIDE PROGRAMS
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ABOUT US
STATEWIDE PROGRAMS
TRAINING
TREATMENT
AGENCIES & CLINICIANS
- Agencies
- Clinicians
RESOURCES
Find A Clinic

Parent Child Interaction Therapy (PCIT) Rostering Application

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Parent Child Interaction Therapy (PCIT) Rostering Application

General Information
First Name*
Last Name*
Degree (ex. M.S., M.E.d)*
License (ex. LPC, LPCC)*
Personal Email Address*
Professional Email Address*
Personal Phone Number*
Agency Phone Number*
Agency Name*
Agency Address*
Agency City*
Agency State*
Agency ZIP Code*
Agency County*
Agency Type (ex. residential, inpatient, outpatient)*
Agency Website*
Treatment Information
Have you completed and participated in a 40-hour Essential PCIT Training Program?*
- Yes
- No
Date of training*
MM slash DD slash YYYY
Name of trainer*
Trainer organization*
PCIT training proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.
Have you completed and participated in ongoing case consultation calls as part of your PCIT training?*
- Yes
- No
Date of calls*
MM slash DD slash YYYY
Call trainer name*
Call trainer organization*
PCIT consultation call proof of completion*
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.
Are you nationally certified in PCIT?*
- Yes
- No
National PCIT Certificate
Drop files here or
Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB.
Message (Optional)
Comments
This field is for validation purposes and should be left unchanged.

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