test form PCIT PCIT Application Form Contact InformationAgency Name/Address:* Name* First Last Suffix Title Phone*Email* FaxMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Role (Select one.)* Clinician Supervisior Program/Clinical Director Other If other, please specify role: Names of other clinicians applying from your agency and their roles: Description of Agency, Team, Implementation Plans, and Experience. For the following questions, estimates are fine.1. Overall, what types of populations are served at your agency (e.g., age ranges, diagnostic populations, racial/ethnic populations, SES, etc.)2. In the past 6 months, about how many children between the ages of 2-6 years have been referred to you for treatment? 3. In the past 6 months, when treating a client between the ages of 2‐6 years, about what percentage of your caseload was spent providing:*Individual Child Therapy:Family Therapy with the child present:Family Therapy without the child present: 4. In the past 6 months, how many clients/patients between the ages of 2-6 years have been referred to you for treatment of child disruptive behavior specifically?5. In the past 6 months, what has been the length of an average course of treatment for a child in your practice, assuming successful treatment completion? 1-5 sessions 6-10 sessions 11-15 sessions 16-20 sessions 21-30 sessions 31-50 sessions More than 50 sessions 6. In the past 6 months, what has been the rate of clients failing to successfully complete treatment (e.g., the drop‐out rate) for your caseload or agency as a whole? Less than or equal to 25% Between 26 and 50% Between 51 and 75% Between 76 and 100% 7. What do you consider to be the most common reasons clients/patients drop out of treatment prior to completion?8. Please rate your comfort level in adhering to a manualized, evidenced‐based practice: Very Uncomfortable Somewhat Uncomfortable Unsure Somewhat Comfortable Very Comfortable 9. Please list any evidence‐based practices you currently use in your clinical practice, regardless of whether they are child/family focused.10. Please describe your personal experience with PCIT or other parent training programs including trainer, location, training date, and duration.11. Please list any other clinical training programs in which you are currently enrolled or that you will be involved in during the timeframe of this PCIT training curriculum (January 2019-April 2020).12. What do you hope to achieve by participating in this training?PCIT is a fast‐paced model requiring the therapist to respond to parent and child behaviors in the moment. Review the following two video segments:Link to Video 1Link to Video 2After viewing the video segments, please answer the following questions:13. Based on your review of the video clip what are the components that you find most interesting?14. Based on your review of the video clip what are the components that you find most concerning?15. Based on your review of the video clip, please indicate your overall comfort level in learning to deliver this model: Very Uncomfortable Somewhat Uncomfortable Unsure Somewhat Comfortable Very Comfortable 16. Does your agency have in place appropriate space and equipment for providing PCIT?A childproofed therapy room and separate observation room with either a two‐way mirror or video monitoring. Yes No A communication system (e.g., speaker system, in‐room phone, baby monitor, bug‐in‐the‐ ear) that allows the therapist (in a separate room) to speak in real‐time to the parent during parent‐child interaction and hear the parent‐child interaction. Yes No Capacity to record sessions (and other materials) for review by trainers? Yes No Policy for sharing clinical information (e.g., session videos) with trainers? Yes No Capacity to participate in online teleconferences via website or mobile app (i.e., computers with webcam and microphones, tablets, etc.)? Yes No If these resources are not in place, please describe your agency’s plan to obtain this space and equipment prior to the beginning of the Initial Training Course.17. Clinicians participating in the training are expected to begin providing PCIT approximately 3 months into the Initial Training period.Who will identify and screen clients to ensure that they are appropriate for PCIT treatment?*When will the process of identifying and screening begin?*Expectations (Please initial each item to signify understanding and agreement.)All Clinicians will: Participate in completion of PCIT assessment activities including completion of clinical assessments/measures as introduced through the training for children receiving PCIT throughout treatment.* Attend all training teleconferences and complete any assignments to prepare for training calls.* Submit necessary videos for skills reviews including role plays and session videos.* Participate in the training evaluation including completing questionnaires (e.g., to provide feedback about the training experience) if requested.* Provide PCIT to a minimum of two clients during the consultation call period, with both cases begun within the first six months of training onset and two cases completed before the conclusion of consult calls.*Please elaborate on any challenges in agreeing to the conditions above and proposed solutions:Please upload your CV:*Max. file size: 125 MB.