ABOUT US
Our Team
What We Do
Outcomes
History
Our Funders
TRAINING
Bring Your Own Lunch & Learn
TF-CBT Learning Collaborative
Honoring Children, Mending the Circle (HCMC)
ND Human Trafficking & Complex Trauma 201 Series
Learning Collaborative
Training Portal
TREATMENT
Child & Adolescent Treatments
Adult Treatments
Trauma Screening
AGENCIES & CLINICIANS
Agencies
Clinicians
RESOURCES
CONTACT
Roster Applications
ABOUT US
Our Team
What We Do
Outcomes
History
Our Funders
TRAINING
Bring Your Own Lunch & Learn
TF-CBT Learning Collaborative
Honoring Children, Mending the Circle (HCMC)
ND Human Trafficking & Complex Trauma 201 Series
Learning Collaborative
Training Portal
TREATMENT
Child & Adolescent Treatments
Adult Treatments
Trauma Screening
AGENCIES & CLINICIANS
Agencies
Clinicians
RESOURCES
CONTACT
Roster Applications
Parent Child Interaction Therapy (PCIT) Rostering Application
Home
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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Select files
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
Select files
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
Select files
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.
78642
© 2024 Treatment Collaborative for Traumatized Youth. All rights reserved.