Dear Parent:Thank you for your interest in Parent-Child Interaction Therapy (PCIT) services at the Mailman Center for Child Development at the University of Miami, Miller School of Medicine. In order for us to best help your child, we ask that you complete the enclosed form. This form will take approximately 15-20 minutes to complete. You will be asked questions about your family's background, your child's medical history, your child's development and behavior, and your child's education. The purpose of completing this form is to see if your family meets the criteria for taking part in our PCIT research study.You may choose not to answer these questions. You may choose to stop completing the form at any time. Your completion of this form is completely voluntary. If you refuse to answer the questions or stop answering them at any time, there will be no penalty, and you will not lose any benefits to which you would otherwise be entitled. Information about your family that you give to PCIT staff from this form will be kept as confidential as possible, as required by law. The risk to completing this form is very small, but it is possible that some people may feel uncomfortable answering these questions. If you qualify to take part in the study and are interested in taking part, then your name and information will be recorded by PCIT staff; this will be kept confidential, but there is a small risk that people outside of the research team could learn this information. For example, email, fax, and mail are not always secure forms of communicating. If you are not interested in the study, then PCIT staff will destroy the personal information you provide. The benefit to you completing the form is that you will find out whether you can take part in our PCIT study. This involves your family receiving free weekly therapy for your child's behavior and your relationship with your child. If you do not wish to complete this form, you can call 2-1-1 for a list of other therapy options for your family. Answering these questions will help us better understand the concerns you have about your child and help us determine whether PCIT would be a good fit for your family's needs. If you would like more information regarding our PCIT program, please visit our website .
Once we receive your completed form, we will contact you regarding your status within two business days. If it is decided that another service or facility would be more helpful for your child, we will provide you with that referral information. Please be sure to add the proper postage to prevent any delays. You can fax completed forms to 305-243-4512 or email them to PCIT@med.miami.edu. Forms can also be mailed to: PCIT, 1601 NW 12th Ave., Miami, FL 33136 . If you feel like you need assistance completing these forms, please contact us at 305-243-0234 and one of our staff will assist you in completing the form over the phone.
If you have any other questions please call at (305) 243-0234. We look forward to speaking with you.
Thank you,
Jason Jent, Ph.D.
Allison Weinstein, Ph.D.
Eileen Davis, Ph.D.
Dainelys Garcia, Ph.D.
Meaghan Parlade, Ph.D.
Today's date:
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Today M-D-Y
Do you live in Miami-Dade County ?
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Yes
No
Forms completed by (full name)
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YOUR First AND Last Name
YOUR phone number
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YOUR email address
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YOUR preferred language
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English
Spanish
Creole
Other
Please specify:
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Child name:
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First AND Last Name
How old is ______ ?
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1 year old 2 years old 3 years old 4 years old 5 years old 6 years old 7 years old 8 years old 9 years old 10 years old 11 years old 12 years old 13+ years old
Are you this child's legal guardian?
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Yes
No
UM PCIT provide services at multiple locations throughout Miami-Dade County to meet the unique needs of families. The type of programs offered at each site slightly differ. A brief description of each program is listed below:
PCIT Description :
Populations Served :
Locations Available :
PCIT with in-home support Description :
Populations Served :
Locations Available :
I-PCIT Description :
Populations Served :
Locations Available :
Directions: Please indicate your availability for appointments (one hour per week) for each location you would be interested in receiving services. We will place you on the waitlist for the times you selected below, and will offer you the first opening. When choosing time slots, keep in mind that later afternoon times have longer waiting periods than earlier time slots.
Please indicate your preferred time(s) at Mailman Center for Child Development
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Please indicate your preferred time(s) at i-PCIT
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UM PCIT Kendall:
Please indicate your preferred time(s) at UM PCIT Kendall (Virtual Only) (Virtual Only) (Virtual Only)
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UM PCIT Homestead:
Temporarily not accepting new clients
Please indicate your preferred time(s) at UM PCIT Homestead
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Coral Gables Campus:
Please indicate your preferred time(s) at Coral Gables Campus Services available in English for children with Autism Spectrum Disorder
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UM PCIT Overtown: Temporarily not accepting new clients
Please indicate your preferred time(s) at UM PCIT Overtown
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UM PCIT Little Havana:
Please indicate your preferred time(s) at UM PCIT Little Havana
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Once your eligibility for our program has been determined, your family will be placed onto our waitlist. Time on the waitlist may vary depending on your availability and location preference. Please call our office for approximate waitlist time.
Directions: Please complete the following questions. If a question is not applicable, please note Not Applicable or N/A as the response. The information provided below will help us better understand your family's specific needs or concerns in order for us to provide the best care.
If you would prefer to complete this form over the phone with a staff member, please selected Yes and provide preferred days and times to be contacted:
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Yes
No
Please list the days and times
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