Request for Information About PCIT Training
RequiredRequired Question(s)
Thanks for your interest in our PCIT training programs for mental health professionals.
 
Please enter the information indicated below so we can reply to your request. This information is never shared with others outside of Kurtz Psychology.

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First Name:
Last Name:
Job Title:
Company Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
City:
State/Province
(US/Canada):
Country:

Required
What is your current employment or training status?
LIcensed for independent practice
Accruing hours towards licensure
In graduate school
Other  
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What is your highest degree earned to date?
PhD, PsyD
Masters degree
MD, DO, NP, PA or other medical degree
Other  
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Are you a licensed mental health professional?
Yes
No
Required
What state are you licensed in? If not yet licensed, write "NOT YET LICENSED."
 

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What is your license number? If not yet licensed, write "NOT YET LICENSED."
 

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What discipline is your license in, or which discipline are your working towards licensure in? 
Psychology
Social Work
Mental Health Counselor
Professional Counselor
Marriage and Family Therapy
Psychiatry
Other  
Required
Will you have access to a completely"stripped room" to conduct all PCIT sessions. A completely stripped room essentially means nothing but the toys you want the child and caregiver playing with, table/counter, and 2 chairs. It means no phones, computers, plants, wires, drawers that open, etc. We can talk about ways to accomplish this in different settings but is part of PCIT integrity.
Yes, currently have stripped room
Yes, anticipate having such a stripped room
No and not sure how I would work this out.
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Do you currently have a one-way mirror setup or will you be using a separate room with some sort of video feed?
Yes, we currently have a one-way mirror setup.
We will have the one-way mirror setup by the time I would be attending your next training.
No, we would be using a ive, contemporaneous video feed from an adjacent room.
Other  
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Please enter website URL of your current work position if you have one. Enter "NO WEBSITE" if there is none.

 

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