PCIT-OK Training Registration Form

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6rQzAdfHr57GzIbi92ndGdgUUHtUqfmSBo6qrLzR6tBdBIJgBwAJ6R4GHfKiEDYmPckI6WVNZKZEb2FMw3eMoDVj3d

First Name

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Last Name

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What are your pronouns?

Work Email

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Personal Email

Training Type

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Basic PCIT Therapist Training

Within Agency Trainer (WAT) Training

Recalibration Training

CARE Training

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Are you currently certified by PCIT International as a PCIT therapist?

Yes

No, explain:

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What is your current certification status with PCIT International?

Certified as a PCIT therapist, active

Certified as a PCIT therapist, inactive (have not been active in last 2 years)

I am not certified as a PCIT therapist with PCIT International (pcit.org)

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When were you certified by PCIT International?

Please list the certified trainer who completed your basic PCIT training. As part of our standard process and in keeping with PCIT International standards, we will contact them briefly to confirm your certification status if you are not listed on the pcit.org website of providers.

Certified Trainer's First and Last Name

Certified Trainer's Contact E-mail

To be eligible for this training, you must have completed 40 hours of initial basic training. Please list the trainer who completed your basic PCIT training. As part of our standard process and in keeping with PCIT International standards, we will contact them briefly to confirm which competencies you have already completed toward certification. If you have not completed didactic training hours, consider our basic training option at https://www.pcitok.org/pcit-therapist-certification

Trainer's First and Last Name

Trainer's Contact E-mail

To be eligible for this training, you must be certified as a therapist by PCIT International. If you have not completed didactic training hours, consider our basic training option at https://www.pcitok.org/pcit-therapist-certification. If you have completed the didactic workshop but did not finish all certification requirements, please consider our Recalibration Training option at https://www.pcitok.org/recalibration-training.

Which of the following best describes your interest in Recalibration Training?

I started the certification process without finishing and would like to continue

I am already certified and want to sharpen my skills

I am already certified and preparing for WAT training

Another reason:

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How many PCIT cases have you graduated?

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How many PCIT cases do you typically hold on your caseload now?

Part of WAT training includes your provision of training to a trainee. Which of the following best describes your situation?

I have a trainee identified who is a licensed clinician or candidate at my agency

I have a trainee identified who has a time-limited position at my agency (e.g., practicum student, intern)

I do not have a trainee identified yet, but my agency is hiring a long-term clinician

I do not have a trainee identified yet, but my agency has time-limited trainee(s) starting

I am unsure if I will have a trainee in the next year

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What agency or which trainer(s) completed your basic training?

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Credentials/Degree

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Agency

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Street Address

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Street Address 2

P.O. Box

City

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State/Country

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Zip

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Phone 1

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Phone 1 Extension

Phone 2

Phone 2 Extension

Fax

Dates of Training (per our website) for which you are applying.

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Name of Agency Representative who is supporting your training (if you practice independently, you may list yourself)

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Agency Representative E-mail (if you practice independently, you may list your e-mail)

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Are you a member of, or is your agency part of, the National Child Traumatic Stress Network (NCTSN)?

* must provide value

Yes

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You may be eligible for a training scholarship through NCTSN. Our coordinator will be in contact with you to determine this. Which membership category is your agency?

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Category I (UCLA or Duke)

Category II

Category III

Affiliate

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Can you provide services in a language other than English?

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Yes

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Please indicate below which languages you can provide services in:

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Spanish

Other

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As part of PCIT certification with PCIT International, your trainer(s) are required to evaluate your delivery of PCIT supervision to fidelity. This involves either watching supervised session recordings or observing live sessions. A Business Associate Agreement, or BAA, is necessary to protect you, your trainee(s), and your clients under HIPAA when this kind of review takes place. A BAA is a legal document that is required under HIPAA whenever Protected Health Information (PHI), like a session, is shared with someone outside your organization who will access that information to do work on your behalf. The BAA sets clear rules about what can and can't be done with that information, and outlines how it must be protected. It ensures that PHI is only used for the purposes of meeting your training requirements, and nothing more.

Please identify the Point of Contact in your organization who can sign this agreement. This must be someone who is authorized to approve contracts on behalf of your organization. If you're unsure who that person is for you, please confirm before completing this form. Typically, this is the owner or director of your practice, a Compliance or Privacy Officer, a Contracts Manager, or Legal Counsel.

I am able to complete this agreement. You can contact me directly.

Someone else in my organization is authorized to complete this agreement.

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As part of PCIT certification with PCIT International, your trainer(s) are required to evaluate your delivery of PCIT to fidelity. This involves either watching session recordings or observing live sessions. A Business Associate Agreement, or BAA, is necessary to protect you and your clients under HIPAA when this kind of review takes place. A BAA is a legal document that is required under HIPAA whenever Protected Health Information (PHI), like a session, is shared with someone outside your organization who will access that information to do work on your behalf. The BAA sets clear rules about what can and can't be done with that information, and outlines how it must be protected. It ensures that PHI is only used for the purposes of meeting your training requirements, and nothing more.

I am able to complete this agreement. You can contact me directly.

Someone else in my organization is authorized to complete this agreement.

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Point of Contact Name

Point of Contact E-Mail

Thank you for your interest in training with the PCIT-OK Training Team. Our training coordinator, Odyssey Bagby, will be in touch with you about next steps. Please note completion of this registration form does not guarantee access to the training you selected. We look forward to working with you!

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