We are updating the PCIT provider map to include more details that will make it easier for families to get connected to services at your agency. Please complete this quick survey by 2/1 in order for your details to be included in the provider map update. 

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* 1. Provider Name

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* 2. Certification Title: Certified Therapist, Level I Trainer, Level II Trainer, or Master Trainer

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* 3. Title of agency/institution where PCIT services are offered

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* 4. Physical street address of agency (the address that could be mapped via GPS that would help a family get to your location)

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* 5. Office Suite # or Room #

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* 6. City

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* 7. State/Province/Territory/Region (enter what you would list in Google Maps to find your physical address)

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* 8. Zip Code

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* 9. Country

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* 10. Provide the email address of the contact person at your institution that can help families get started with services (This may or may not be a therapist or trainer. It may be an intake specialist or a general agency email address that is used for these purposes)

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* 11. Provide the phone number that families should call at your agency if they are seeking to schedule an appointment for services (e.g., agency intake appointment line)

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* 12. Provide a website address for your agency that either provides more details about PCIT for your agency or would help families learn about how to schedule an appointment

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* 13. Please list the certified trainers and therapists that provide services at your institution in the following order (Certified Therapists, Level I Trainers, Level II Trainers, and Master Trainers). Please separate each therapist name by a comma

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* 14. Types of payment for services accepted (Select all that apply):

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