DATA TEAM ONLY:
Check if this form completed via phone screening?
Phone screening completed by:
New call: Hello, may I please speak to [parent name]? Hello, [parent name] my name is [your name] and I am calling from the Parent-Child Interaction Therapy Clinic at the University of Miami.
Returning call: Hello, this is [your name] from the Parent-Child Interaction Therapy Clinic at the University of Miami. I'm returning a phone call.
I can tell you a little about our program. Parent-Child Interaction Therapy or PCIT is a parenting program that is supported by over 30 years of research. Caregivers learn play therapy skills and behavior management strategies to strengthen the caregiver-child relationship and improve child behavior. We have two programs that focus on your child's individual needs: one program focuses on improving child behavior including following instructions, compliance, effective discipline strategies, and tools to help in reducing tantrums; and a second program that helps caregivers learn ways to support their child in confronting anxiety-provoking situations (such as fear when away from caregivers, sleeping alone, or fear of specific places or things).
You practice these skills with your child in weekly sessions and daily at home. Sessions are usually weekly for 12-16 weeks for approximately an hour. They will be the same day and the same time assuming that it works with the therapist.
Last thing about our program is that we are funded through the Children's Trust, which allows us to provide free therapy services for families in Miami- Dade County.
The next step is for you to fill out a background information form. This next portion we are required to express for research purposes [see Dear Parent/Caregiver section]:
At the University of Miami Parent-Child Interaction Therapy (PCIT) Program, we support families with young children who may be having challenges with behavior, emotions, or anxiety.We offer two programs: 1) PCIT for children ages 2 to 7 years with behavior challenges 2) PCIT-CALM for children ages 3 to 9 years with worries, fears, or anxiety These programs help families learn positive, practical strategies to strengthen their relationship with their child and support their child's emotional and behavioral growth. Our services are currently only available for families who live in Miami-Dade County. Do you live in Miami-Dade County?
* must provide value
Yes
No
Thank you for your interest in the University of Miami PCIT Program. At this time, our Children's Trust-funded services are only available for families who live in Miami-Dade County.
To learn about programs and services in your community, you can call 2-1-1 , a free and confidential resource that connects families with local supports.
If you have any questions or would like to talk more about your application, please feel free to contact us:
Phone: 305-243-0234Email: pcit@med.miami.edu
We wish you and your family the best!
Dear Parent/Caregiver:
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!
Today's date: CHILD INFORMATION
Child's name:
First:
Middle:
Last:
Child DOB:
Child age:
Child's gender:
Do you have any concerns about your child's behavior (for example, tantrums, not following directions, aggression, or defiance
Do you have any concerns about your child's emotions or worries (for example, anxiety, fears, or being very shy/withdrawn)?
Has your child ever been diagnosed with Autism Spectrum Disorder, or do you have any concerns about your child's development related to autism?
PARENT/CAREGIVER INFORMATION
Primary caregiver
First:
Last:
Relationship to child:
Preferred language for services:
Phone number:
Email:
Address:
Street:
City:
Are you this child's legal guardian?
Secondary caregiver
First:
Last:
Relationship to child:
Preferred language for services:
Phone number:
Email:
Address:
Street:
City:
Have you received Parent-Child Interaction Therapy (PCIT) or CALM services before?
Where have you received services?
Please note: The following question refers only to child welfare or Child Protective Services involvement related to child safety/well-being. It does not refer to SNAP/food stamps, Medicaid, WIC, or other public benefits.
Have you or any of your child's caregivers ever (past/present) been involved with Child Protective Services (such as Department of Children and Families [DCF])?
*If this question applies please provide any additional information (for example: case manager contact, case open/closed)
How did you hear about us?
Thank you for your interest in the University of Miami PCIT Program. At this time, our Children's Trust-funded services are available for children between 2 and 12 years old , and based on the information you shared, your child is outside of this age range.
To learn about programs and services in your community, you can call 2-1-1 , a free and confidential resource that connects families with local supports.
If you have any questions or would like to talk more about your application, please feel free to contact us: Phone: 305-243-0234Email: pcit@med.miami.edu
We wish you and your family the best!
Directions: The UM PCIT Program offers services at several locations throughout Miami-Dade County to support families. You can receive services in the clinic, virtually (online), or through a hybrid option that combines both in-person and virtual appointments. Please note that at least one session must be completed in-person , regardless of the option you choose.
Please select the checkbox next to how you would like to receive services . You may choose more than one option and indicate your availability for one-hour weekly appointments. Once your eligibility has been confirmed, our staff will contact you before being placed on our waitlist. Wait times may vary depending on your availability and preferred location. Please keep in mind that later afternoon appointments may have longer wait times than earlier appointments.
Virtual PCIT Virtual PCIT is delivered through secure Zoom sessions, allowing families to receive coaching while playing with their child at home. Limited internet hotspots and equipment may be available. Would you need any equipment?
Hours: (earliest appointment time - last appointment time)
Monday: 9 AM - 5 PMTuesday: 8 AM - 5 PMWednesday: 9 AM - 5 PMThursday: 9 AM - 5 PM
Virtual PCIT Hours: Temporarily not accepting new clients
In-Clinic: Mailman Center for Child Development Address: 1601 NW 12th Ave, Miami, FL 33136 Hours: (earliest appointment time - last appointment time)
Monday: 9 AM - 5 PMTuesday: 9 AM - 5 PMWednesday: 8 AM - 5 PMThursday: 9 AM - 5 PM
In-Clinic : Mailman Center for Child Development Address: 1601 NW 12th Ave, Miami, FL 33136 Hours: Temporarily not accepting new clients
In-Clinic : Coral Gables Address: 5665 Ponce De Leon Blvd, Coral Gables, FL 33146 Hours: (earliest appointment time - last appointment time)
Tuesday: 3 PM - 4 PM Wednesday: 2 PM - 3 PM *serves children with autism and English-speaking families only
In-Clinic : Coral Gables Address: 5665 Ponce De Leon Blvd, Coral Gables, FL 33146 Hours: Temporarily not accepting new clients
In-Clinic : Kendall Address: 10691 N Kendall Dr, Suite 203, Miami, FL 33176 Hours: (earliest appointment time - last appointment time)
Monday: 11 AM - 5 PMThursday: 10 AM - 5 PM
In-Clinic : Kendall Address: 10691 N Kendall Dr, Suite 203, Miami, FL 33176 Hours: Temporarily not accepting new clients
In-Clinic : Little Havana (ConnectFamilias) Address: 1111 SW 8th Street, Suite 207, Miami, FL 33130 Hours: (earliest appointment time - last appointment time)
Wednesday: 11 AM - 6 PMThursday: 10 AM - 6 PM
In-Home Support Option: At three satellite clinic locations (Little Havana, Overtown, and Homestead), families may also receive additional in-home support from a community specialist to help practice skills and connect with local resources.
In-Clinic: Little Havana (ConnectFamilias) Address: 1111 SW 8th Street, Suite 207, Miami, FL 33130Hours: Temporarily not accepting new clients
In-Clinic : Overtown (Touching Miami with Love) Address: 711 NW 6th Ave, Miami, FL 33136 Hours: (earliest appointment time - last appointment time)
Wednesday: 9 AM - 5 PMThursday: 9 AM - 5 PM
In-Home Support Option: At three satellite clinic locations (Little Havana, Overtown, and Homestead), families may also receive additional in-home support from a community specialist to help practice skills and connect with local resources.
In-Clinic: Overtown (Touching Miami with Love) Address: 711 NW 6th Ave, Miami, FL 33136Hours: Temporarily not accepting new clients
In-Clinic: Homestead (Touching Miami with Love) Address: 1350 SW 4th Street, Homestead, FL 33030 Hours: (earliest appointment time - last appointment time)
Monday: 9 AM - 5 PMTuesday: 9 AM - 5 PMWednesday: 9 AM - 5 PMThursday: 10 AM - 6 PM
In-Home Support Option: At three satellite clinic locations (Little Havana, Overtown, and Homestead), families may also receive additional in-home support from a community specialist to help practice skills and connect with local resources.
In-Clinic: Homestead (Touching Miami with Love) Address: 1350 SW 4th Street, Homestead, FL 33030 Hours: Temporarily not accepting new clients
Please indicate how you would like to receive PCIT services.
In-Person
Virtual
Hybrid (a combination of in-person and virtual)
1 session must be completed in-person regardless of virtual or hybrid selection
DATA TEAM ONLY: Check if this form completed via phone screening?
Check if C2 data not available
Check if C2 data not available
Today's date:
* must provide value
Today M-D-Y
Child First Name:
* must provide value
Child Last Name:
* must provide value
Child date of birth
* must provide value
M-D-Y
View equation
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 14 years old 15 years old 16 years old 17 years old 18 years old
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
Gender
* must provide value
Male Female Other
Please specify
* must provide value
Has your child ever been diagnosed with Autism Spectrum Disorder, or do you have any concerns about your child's development related to autism?
* must provide value
Yes No
Do you have any concerns about your child's behavior (for example, tantrums, not following directions, aggression, or defiance)?
* must provide value
Yes No
Do you have any concerns about your child's emotions or worries (for example, anxiety, fears, or being very shy/withdrawn)?
Yes No
Primary caregiver's first name
* must provide value
Primary caregiver's last name
* must provide value
Primary caregiver's Relationship to child
* must provide value
Mother Father Step-mother Step-father Grandmother Grandfather Adoptive mother Adoptive father Aunt Uncle Other
Please specify
* must provide value
Primary caregiver's Cell phone
* must provide value
Primary caregiver's Email address
* must provide value
Home address
* must provide value
State
* must provide value
Zip Code
* must provide value
Primary caregiver's preferred language
* must provide value
English Spanish Creole Other
Please specify
* must provide value
Primary caregiver's- Are you this child's legal guardian?
* must provide value
Yes No
Have you and your child ever received Parent-Child Interaction Therapy (PCIT) or CALM services before?
* must provide value
Yes No
Where have you received PCIT/CALM services?
* must provide value
Have you or any of the child's primary caregivers ever been involved with Child Protective Services (e.g., Department of Children and Families [DCF], etc.)?
* must provide value
Yes No
Please provide any additional information (for example: case manager contact, case open/closed)
* must provide value
Forms completed by (full name)
* must provide value
YOUR First AND Last Name
Secondary caregiver's name
* must provide value
English
Spanish
Creole
Other
Secondary caregiver's first name
Secondary caregiver's last name
Mother Father Step-mother Step-father Grandmother Grandfather Adoptive mother Adoptive father Aunt Uncle Other
Secondary caregiver's preferred language
English Spanish Creole Other
Secondary caregiver's Cell phone
Secondary caregiver's Email address
How did you hear about us?
* must provide value
Allied Health Professional (SLT/OT/PT) Behavioral Health Brochure CARD ConnectFamilias DEP Early Discovery Early Steps Facebook Friend/Family Google Healthy Steps Insurance Company Instagram Nicklaus Children's Hospital Neurologist Other MD Parent to Parent Parent Club Pediatrician Previously Enrolled in PCIT School Talk/Presentation TCT Expo Touching Miami with Love (TML) UChart Other (please specify)
If you start virtual services with us in the future, would you need any equipment? Our team offers families equipment such as bluetooth headsets, internet hotspots, tablets, and cameras.
Yes
No
What type of equipment would you need?
UM PCIT Kendall:
UM PCIT Homestead:
Temporarily not accepting new clients
Coral Gables Campus:
UM PCIT Overtown:
Call to ask for availability
UM PCIT Little Havana:
View equation Thank you for your interest in the University of Miami Parent-Child Interaction Therapy (PCIT) Program. At this time, we are not enrolling new families due to an extensive waitlist. We encourage you to review the referral resources listed below for alternative services and support options.
Citrus Health Network- Parent Child Interaction Therapy, Phone: 305-424-3043 Email Address: ecdreferral@citrushealth.com Available Days: Monday-Friday Clinic hours: 9:00-5:30 (Last appointment time in person but if session is health via telehealth the session could potentially be seen at later times) Locations: In-Person/Virtual/Hybrid Cost: FREE (funded by TCT) Eligibility: Live in Miami Dade Language Availability: English and Spanish Triple P- Positive Parenting Program* (age 2-12), Phone: 305-796-1139 Triple P Parenting Program is for parents with children who have mild to moderate behavioral issues Consists of 10 FREE, 1 hour, parenting sessions with a Triple P Parent Educator Parents will learn and practice the skills necessary to tackle behavioral challenges with various Sessions in English or Spanish, in-home or virtual. Email: janet@fofmiami.org If you have any questions or would like additional information, please contact us at pcit@med.miami.edu or (305) 243-0234.