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PCIT Provider and Trainer Contact Information Updated Details
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Therapist/Trainer Name
Your answer
Certification Type-
Certified Therapist
Within-Agency Trainer
Regional Trainer
Global Trainer
Name of Practice/Agency
Your answer
Street Address
Your answer
Suite/Floor #
Your answer
City
Your answer
State/Province
Your answer
Zipcode
Your answer
Country
Your answer
Check if providing Internet-Based PCIT: Virtual therapy.
Virtual Services (iPCIT)
Please select the State(s) in which you are licensed to provide care in
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
States
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
States
Professional or agency email address
Your answer
Professional Office phone #
Your answer
Agency/Institution Website
Your answer
List of providers at your agency providing PCIT services; please separate names with a comma
Your answer
Federal Insurance Programs and Private Health Insurance
free; restrictions apply (e.g., grant or study eligibility)
Federal insurance programs (e.g., Medicaid, Medicare, government insurance, national health insurance)
Private health insurance
Out-of-network provider (billed for services and submit to insurance for reimbursement)
Self-pay sliding scale (based on family income)
Self-pay professional rate
Other:
Comments
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