PCIT Certification Experience Fee: $135.00 Certification Processing and Recording Fee: $35.00 Total PCIT Therapist Certification Experience Fee: $225.00 Returned Fee: $50.00 PCIT Certified Therapist Application IDENTIFYING INFORMATION Full Name: Agency/Institution: Address: Phone number: Email: of Clinical Years at Current Agency: Practice: GRADUATE EDUCATION Highest Degree Field of highest degree completed Completed (MS, PhD, (social work, counseling PsyD, etc.): psychology, clinical psychology, etc.): Date of Degree Institution: (MM/YYYY): Licensure State Type Number (LCSW, LMFT, LPC, HSP, etc.)
PCIT Certification Experience Fee: $135.00 Certification Processing and Recording Fee: $35.00 Total PCIT Therapist Certification Experience Fee: $225.00 Returned Fee: $50.00 PCIT Certified Therapist Application IDENTIFYING INFORMATION Full Name: Agency/Institution: Address: Phone number: Email: of Clinical Practice: Years at Current Agency: GRADUATE EDUCATION Highest Degree Completed (MS, PhD, PsyD, etc.): Field of highest degree completed (social work, counseling psychology, clinical psychology, etc.): Date of Degree (MM/YYYY): Institution: Licensure State Type (LCSW, LMFT, LPC, HSP, etc.) Number
pcit_certified_therapist_application_updated_july__2014.docx