Request for Information About PCIT Within Agency Trainer Training
RequiredRequired Question(s)
Thanks for your interest in our PCIT training program to become a Within Agency Trainer (WAT).
 
Please enter the information indicated below so we can reply to your request. This information is never shared with others outside of Kurtz Psychology.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

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  
  • Comment:

  • 500 characters left.
Required
What is your highest degree earned to date?
PhD, PsyD
Masters degree
MD, DO, NP, PA or other medical degree
Other  
  • Comment:

  • 500 characters left.
Required
Are you a licensed mental health professional?
Yes
No
Required
What state are you licensed in? If not yet licensed, write "NOT YET LICENSED."
 

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

50 characters left.
Required
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
What is your current PCIT International certification status?
Certified Therapist who graduated 2 or 3 cases to date.
Certified Therapist who graduated 4 cases to date.
Being trained by a PCIT International certified trainer but not yet graduated my second case.
Trained under UC Davis
Other  
  • Comment:

  • 500 characters left.
Required
Who do you anticipate training for your WAT training process? Please describe, as best you can, how many individuals and what their professional training levels are, e.g., licensed, accruing licensure hours, graduate students.  The more detailed your answer the better I can help you determine if this is a good fit for you at this time.
 

350 characters left.
Required

 

350 characters left.
Required

Please enter website URL of your current work position if you have one. Enter "NO WEBSITE" if there is none.

 

50 characters left.
Required
Are there any other WATs in your agency at this time?
Yes, there are already certified WATs in our agency.
There are WATs in training at this time.
There are no WATs in our agency and none in training to become WATs.
Other  
  • Comment:

  • 500 characters left.
Required

Who was your trainer of record for your PCIT Certification?

 

50 characters left.