I attest I have read, understand, and agree to the expectations found within the PCIT Implementation Overview and Cohort Milestones documents.
name of person completing application
* must provide value
I attest I have read and agree to the expectations found within the PCIT Information Sheet, PCIT Implementation Overview, PCIT Agency Checklist, and PCIT Training Milestones:
* must provide value
Agency Director ( First and Last Name)
* must provide value
First and Last Name
Email
Clinical Supervisor ( First and Last Name)
* must provide value
First and Last Name
Email
Name of Agency Address Phone Number Agency Director Clinical Supervisor
Please email the completed application to:
* must provide value
Street Address
Street Address Line 2
City
Phone Number
Therapist qualifications, caseload, and training requirements Allowing and facilitating therapists’ time away from clinical duties to participate in training, which includes five partial days of virtual face-to-face training for the introductory workshop (April 19, 20, 21, 24, 25) and four additional partial days of virtual face-to-face training for the follow-up workshop 4 months later (August 24, 25, 28, 29). A final virtual face-to-face booster training may take place over 1 full day or 2 partial days approximately 12 months after the introductory workshop. Supporting therapists’ participation in 18 months of Zoom consultation calls (scheduled twice monthly, starting after the introductory workshop) so they are able to attend at least 80% of calls by the end of training. Supporting therapists’ tasks that involve 1) updating an on-line spreadsheet in Box to track case progress before each consultation call, and 2) submitting four video recorded sessions to trainers for fidelity review. Promoting understanding among staff and leadership of the potentially unusual needs and requirements of successful PCIT cases (e.g., weekly attendance expectations, possibility of “noisy” sessions). How are you communicating to your therapists expectations for any missed clinic days for training? Are they required to make-up productivity?
Therapists need to maintain a PCIT caseload of approximately four cases weekly to optimize their ability to complete the required two full cases within 18 months. How will you ensure your agency’s therapists are receiving a sufficient number of PCIT-appropriate referrals to meet this requirement? For example, sending four therapists to train in PCIT would require 16 families in PCIT weekly.
List your local referral sources where publicity materials will be sent (e.g., advertising PCIT in your area, seeking referrals from pediatricians and daycares, etc.) when therapists are accepted into training.
In the past year, how many of your agency's outpatient clients could potentially meet PCIT criteria (e.g., using EMR, # of clients ages 2 - 6 years old)?
What percentage of these children could be seen with their caregivers?
Infrastructure Needs PCIT Therapy Room
Creating or repurposing a fully or partially dedicated PCIT therapy room: A safe, relatively low-stimulation room for a caregiver and a child to engage in free play with a small selection of toys. Room should have three adult sized chairs, a sturdy adult sized table, and nothing else except the toy sets the therapist has brought in for that session, which are the only toys accessible and visible to the child.
PCIT Room Example
Will your agency need to complete any construction or remolding for your PCIT Therapy Room Observation Room or Timeout Area?
Briefly describe the PCIT room in your clinic:
If you have picture of your PCIT room, please upload that to this application?
Observation Room
A room allowing a PCIT therapist to see and hear the caregiver and child playing, speak to the caregiver, and be out of the child’s sight and hearing. PCIT observation can be conducted through a live video feed or by using a one-way mirror.
PCIT Observation Room Example
Please indicate below which option your agency will pursue.
Time-Out Backup Area (two options)
Option 1, Traditional Time-out Backup Area (recommended): A safe, non-stimulating area for temporary use while child is learning to comply with timeout chair procedure; child is visible by the caregiver and/or therapist when in the area; barriers are built into the surrounding walls/corners and are 5 feet tall — baby gates are not sufficient and could pose a danger to the child and caregiver if the child throws them.
Timeout Area Example
Option 2, Swoop and Go: If a time-out backup area cannot be constructed or requires additional time, an agency can use the Swoop and Go procedure. For children who leave the time-out chair, the caregiver quickly removes as many toys from the room as possible and exits the room with a laundry basket or large container. The child remains under observation by the therapist from the observation room, and the caregiver waits immediately outside the door. This option requires that the room is in a location where the caregiver could wait outside the door without disturbing other client sessions and the caregiver can prevent the child from leaving the room (e.g., by holding the doorknob).
Please indicate below which option your agency will pursue.
Audio Visual Equipment
For the Room: Purchasing and maintaining an audio system enabling 1) the therapist to hear the caregiver and child and 2) the therapist to speak to the caregiver without the child hearing. For Video Review: Providing technology to record sessions that can be uploaded or otherwise securely delivered to UAMS trainers for video review of therapist sessions (e.g., video camera, laptop). Video must contain child, caregiver, and therapist. For Consulation Calls: Providing technology to participate in consultation calls that includes a webcam and speakers. Contact Information for your agency's IT Department, for assistance and/or consultation regarding the audio and video technology described above.
Will your agency need to purchase any audio visual equipment?
Briefly describe the audio and video equipment you have or will purchase for PCIT in your clinic.
Supplies and Resources Is your agency currently using telehealth with clients? PCIT delivered via telehealth has been shown to be as effective as clinic-based services when conducted in the family's home. If sessions are conducted via telehealth, therapists will need access to a computer, speakers, webcam, and a HIPPA compliant telehealth service. Purchasing and maintaining a supply of appropriate PCIT toys: Creative, constructive toys that encourage free play with little need for limit setting and have little potential to be used dangerously.
Toys: Creative, constructive toys appropriate for ages 2-6 that encourage free play with little need for limit setting. Required: One large plush bear (2-3 feet tall, for timeout role-plays later in treatment). Recomendations: Building toys: Soft (foam) blocks, Tinkertoys, Legos, Duplos, magnetic tiles; crayons, paper, and coloring sheets; play food; Potato Head; play sets such as farms, houses, zoo animals, garage ramp with cars; train sets. AVOID toys that: are hard, messy, sharp, and/or easily breakable (e.g., markers, wooden blocks); encourage aggression, rough play, and/or violent themes (e.g., action figures, balls and bats); have rules (e.g., board games, card games), and/or are electronic.
Purchasing one 2011 PCIT Protocol, one DPICS-IV Manual, and one Clinical DPICS-IV Workbook for each therapist completing PCIT Training.
Having ability for therapists to easily make copies of handouts from the PCIT protocol.
Purchasing one Eyberg Child Behavior Inventory (ECBI) manual for the clinic.
Maintaining a supply of the Eyberg Child Behavior Inventory (ECBI) for weekly use with clients.
Providing appropriate furniture for PCIT sessions: Three sturdy adult-size chairs and a sturdy adult-size table.
Allowing and facilitating therapists’ time away from clinical duties to participate in training, which includes five partial days of virtual face-to-face training for the introductory workshop (April 19, 20, 21, 24, 25) and four additional partial days of virtual face-to-face training for the follow-up workshop 4 months later (August 24, 25, 28, 29). A final virtual face-to-face booster training may take place over 1 full day or 2 partial days approximately 12 months after the introductory workshop.
* must provide value
Supporting therapists’ participation in 18 months of Zoom consultation calls (scheduled twice monthly, starting after the introductory workshop) so they are able to attend at least 80% of calls by the end of training.
* must provide value
Supporting therapists’ tasks that involve 1) updating an on-line spreadsheet in Box to track case progress before each consultation call, and 2) submitting four video recorded sessions to trainers for fidelity review.
* must provide value
Promoting understanding among staff and leadership of the potentially unusual needs and requirements of successful PCIT cases (e.g., weekly attendance expectations, possibility of “noisy” sessions).
* must provide value
How are you communicating to your therapists expectations for any missed clinic days for training? Are they required to make-up productivity?
* must provide value
Therapists need to maintain a PCIT caseload of approximately four cases weekly to optimize their ability to complete the required two full cases within 1 year. How will you ensure your agency’s therapists are receiving a sufficient number of PCIT-appropriate referrals to meet this requirement? For example, sending four therapists to train in PCIT would require 16 families in PCIT weekly.
* must provide value
List your local referral sources where publicity materials will be sent (e.g., advertising PCIT in your area, seeking referrals from pediatricians and daycares, etc.) when therapists are accepted into training.
* must provide value
In the past year, how many of your agency's outpatient clients could potentially meet PCIT criteria (e.g., using EMR, # of clients ages 2 - 6 years old)?
* must provide value
What percentage of these children could be seen with their caregivers?
* must provide value
Will your agency need to complete any construction or remolding for your PCIT Therapy Room Observation Room or Timeout Area?
* must provide value
Yes No
Briefly describe the room you will use as your agency’s PCIT room.
* must provide value
Please indicate below which option your agency will pursue.
Please indicate below which option your agency is pursuing:
* must provide value
Option 1, Observation room adjoining the therapy room, with viewing of therapy room through a one-way
Option 2, Observation via a live video feed, with camera out of child's reach in therapy room.
Other
Please indicate below which option your agency will pursue.
* must provide value
Option 1, Traditional Time-out Backup Area (recommended)
Option 2, Swoop and Go
Other
Purchasing and maintaining an audio system enabling 1) the therapist to hear the caregiver and child and 2) the therapist to speak to the caregiver without the child hearing.
* must provide value
Providing technology to record sessions that can be uploaded or otherwise securely delivered to UAMS trainers for video review of therapist sessions (e.g., video camera, laptop). Video must contain child, caregiver, and therapist.
* must provide value
Providing technology to participate in consultation calls that includes a webcam and speakers.
* must provide value
Contact Information for your agency's IT Department, for assistance and/or consultation regarding the audio and video technology described above.
* must provide value
Need to purchase AV equipment
* must provide value
Yes No
Briefly describe the audio and video equipment you have or will purchase for PCIT in your clinic.
* must provide value
Is your agency currently using telehealth with clients?
* must provide value
Yes No
Purchasing and maintaining a supply of appropriate PCIT toys: Creative, constructive toys that encourage free play with little need for limit setting and have little potential to be used dangerously.
AVOID toys that are hard, messy, sharp, and/or easily breakable (e.g. markers, wooden blocks); encourage aggression, rough playand/or violent themes (e.g. action figures, balls and bats); have rules (e.g. board games, card games); are electronic
* must provide value
Purchasing one 2011 PCIT Protocol, one DPICS-IV Manual, and one Clinical DPICS-IV Workbook for each therapist
* must provide value
Having ability for therapists to easily make copies of handouts from the PCIT protocol. completing PCIT Training
* must provide value
Purchasing one Eyberg Child Behavior Inventory (ECBI) manual for the clinic.
* must provide value
Maintaining a supply of the Eyberg Child Behavior Inventory (ECBI) for weekly use with clients.
* must provide value
Providing appropriate furniture for PCIT sessions: 3 sturdy adult-size chairs and a sturdy adult-size table.
* must provide value
All Trainees that I have listed in this application are aware that I, as their supervisor/agency director, will receive information pertaining to their progress throughout PCIT training.
* must provide value
Yes
No
Trainee(s) Information IMPORTANT:
Please list a good contact email for each trainee. If accepted, this is how we will notify them of their acceptance. If accepted into the training, a PCIT trainer will contact each trainee to discuss possible PCIT-appropriate referrals/families on their current caseload. Trainee #1 Information Primary Office Location
Location(s) where planning to do PCIT
List all of the settings in which the trainee works (e.g., outpatient, school).
How many hours per week does the trainee work at each setting? In the setting(s) in which the trainee is planning to do PCIT... Are they actively treating children ages 2-6 with behavioral problems and their caregivers? How many cases of children ages 2-6 do they see per week? What percentage of those cases could be seen with a caregiver? Direct Supervisor Answer this next set of questions to the best of your ability. Master's degree or higher in a mental health field? Independently licensed or under supervision of licensed MHP? Completed DC:0-5 training? Completed Infant Mental Health Certification? Trainee #2 Information Primary Office Location
Location(s) where planning to do PCIT
List all of the settings in which the trainee works (e.g., outpatient, school). How many hours per week does the trainee work at each setting? In the setting(s) in which the trainee is planning to do PCIT... Are they actively treating children ages 2-6 with behavioral problems and their caregivers? How many cases of children ages 2-6 do they see per week? What percentage of those cases could be seen with a caregiver? Direct Supervisor Answer this next set of questions to the best of your ability. Master's degree or higher in a mental health field? Independently licensed or under supervision of licensed MHP? Completed DC:0-5 training? Completed Infant Mental Health Certification? Trainee #3 Information Primary Office Location
Location(s) where planning to do PCIT
List all of the settings in which the trainee works (e.g., outpatient, school). How many hours per week does the trainee work at each setting? In the setting(s) in which the trainee is planning to do PCIT... Are they actively treating children ages 2-6 with behavioral problems and their caregivers? How many cases of children ages 2-6 do they see per week? What percentage of those cases could be seen with a caregiver? Direct Supervisor Answer this next set of questions to the best of your ability. Master's degree or higher in a mental health field? Independently licensed or under supervision of licensed MHP? Completed DC:0-5 training? Completed Infant Mental Health Certification? Trainee #4 Information Primary Office Location
Location(s) where planning to do PCIT
List all of the settings in which the trainee works (e.g., outpatient, school). How many hours per week does the trainee work at each setting? In the setting(s) in which the trainee is planning to do PCIT... Are they actively treating children ages 2-6 with behavioral problems and their caregivers? How many cases of children ages 2-6 do they see per week? What percentage of those cases could be seen with a caregiver? Direct Supervisor Answer this next set of questions to the best of your ability. Master's degree or higher in a mental health field? Independently licensed or under supervision of licensed MHP ? Completed DC:0-5 training? Completed Infant Mental Health Certification? Trainee #5 Information Primary Office Location
Location(s) where planning to do PCIT
List all of the settings in which the trainee works (e.g., outpatient, school). How many hours per week does the trainee work at each setting? In the setting(s) in which the trainee is planning to do PCIT... Are they actively treating children ages 2-6 with behavioral problems and their caregivers? How many cases of children ages 2-6 do they see per week? What percentage of those cases could be seen with a caregiver? Direct Supervisor Answer this next set of questions to the best of your ability. Master's degree or higher in a mental health field? Independently licensed or under supervision of licensed MHP? Completed DC:0-5 training? Completed Infant Mental Health Certification?
Email (If accepted into the training, this is how we will notify trainees)
* must provide value
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Primary office location (City, County).
* must provide value
Primary office location (City, County).
Primary office location (City, County).
Primary office location (City, County).
Primary office location (City, County).
Location(s) where planning to do PCIT
* must provide value
Location(s) where planning to do PCIT
Location(s) where planning to do PCIT
Location(s) where planning to do PCIT
Location(s) where planning to do PCIT
office setting
* must provide value
client hrs per week
* must provide value
Email (If accepted into the training, this is how we will notify trainees)
* must provide value
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Email (If accepted into the training, this is how we will notify trainees)
Master's degree or higher in mental health field?
* must provide value
Yes No Not Sure
Master's degree or higher in mental health field?
Yes No Not Sure
Master's degree or higher in mental health field?
Yes No Not Sure
Master's degree or higher in mental health field?
Yes No Not Sure
Master's degree or higher in mental health field?
Yes No Not Sure
* must provide value
Yes No Not Sure
Yes No Not Sure
Yes No Not Sure
Yes No Not Sure
Yes No Not Sure
Actively treating children ages 0-5 with mental health, attachment, and/or behavioral problems?
* must provide value
Yes No Not Sure
Actively treating children ages 0-5 with mental health, attachment, and/or behavioral problems?
Yes No Not Sure
Actively treating children ages 0-5 with mental health, attachment, and/or behavioral problems?
Yes No Not Sure
Actively treating children ages 0-5 with mental health, attachment, and/or behavioral problems?
Yes No Not Sure
Actively treating children ages 0-5 with mental health, attachment, and/or behavioral problems?
Yes No Not Sure
how many cases of children's ages 2-7 does this therapist see per week?
* must provide value
how many cases of children's ages 2-7 does this therapist see per week?
how many cases of children's ages 2-7 does this therapist see per week?
how many cases of children's ages 2-7 does this therapist see per week?
how many cases of children's ages 2-7 does this therapist see per week?
what percentage of those cases could be seen with a caregiver?
* must provide value
what percentage of those cases could be seen with a caregiver?
what percentage of those cases could be seen with a caregiver?
what percentage of those cases could be seen with a caregiver?
what percentage of those cases could be seen with a caregiver?
Completed DC:0-5 training
* must provide value
Yes No Not Sure
Completed DC:0-5 training
Yes No Not Sure
Completed DC:0-5 training
Yes No Not Sure
Completed DC:0-5 training
Yes No Not Sure
Completed DC:0-5 training
Yes No Not Sure
Completed Infant Mental Health Certification
* must provide value
Yes No Not Sure
Completed Infant Mental Health Certification
Yes No Not Sure
Completed Infant Mental Health Certification
Yes No Not Sure
Completed Infant Mental Health Certification
Yes No Not Sure
Completed Infant Mental Health Certification
Yes No Not Sure
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