PCIT intake | Mesa Valley Counseling

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What PCIT is

Parent-Child Interaction Therapy is an evidence-based treatment for parents of young children, typically ages 2 to 7, who are showing challenging behaviors. A certified therapist coaches the parent in real time during play and everyday interactions. Child-Directed Interaction (CDI) builds warmth through PRIDE skills: Praise, Reflect, Imitate, Describe, and Enjoy. Parent-Directed Interaction (PDI) teaches clear commands and consistent, calm discipline. Most families finish in about 12–20 weekly hour-long sessions. Progress is based on skill mastery, not a fixed calendar. PCIT is not reunification therapy, family-systems therapy, or joint parent counseling.

I have read this description and understand PCIT is a live-coached parenting skills program. *

When PCIT is court-involved

If the court is involved, both parents support the child’s progress. The custodial parent schedules promptly, does not coach the child on what to say, and keeps session content private. The participating parent attends consistently, practices PRIDE and guidance skills, and completes brief home practice. Written communication is limited. Concerns should be emailed with the other parent copied, except when a protective order or verified domestic violence requires separate contact. Releases are required before the therapist speaks with attorneys or other professionals. Time spent on third-party communication is billable. This practice does not give legal advice.

I understand the court-involved communication rules, including joint email and mandated reporting. *

I will not record sessions. I understand recordings, if used, require notice and consent and are only for training or quality. *

Caregiver and household information

Date of intake *

Referral source

Caregiver 1 name *

Caregiver 1 relationship to child *

Caregiver 1 age

Caregiver 1 email *

Caregiver 1 phone *

Street address *

City, state, ZIP *

Caregiver 2 name (if applicable)

Caregiver 2 relationship to child

Caregiver 2 age

Caregiver 2 email

Caregiver 2 phone

Other household members (names, ages, relationships)

Marital / family status

Custody arrangements, if any

Child information

Child’s full name *

Preferred name or nickname

Date of birth *

Age *

Gender

Preferred pronouns

Current school and grade

Teacher or school contact, if relevant

Who lives with the child most of the time? *

Developmental, medical, and family history

Any delays in speech, motor skills, or social development? *

YesNo

If yes, please describe

Medical history, allergies, hospitalizations

Current medications (name, dose, reason)

Previous diagnoses or evaluations

Has your child experienced traumatic events (abuse, neglect, loss, separation, medical trauma, or violence)? *

YesNo

If yes, share only what you are comfortable disclosing

Child’s strengths and things they enjoy

What would you like to improve in your interactions with your child?

Are you currently experiencing high stress, anxiety, depression, or trauma symptoms?

YesNo

If yes, would you like individual support alongside PCIT?

Family strengths and supports

Culture, values, language, or beliefs that would help us care well for your family

Coaching, contacts, and insurance

Are you comfortable with live observation or video recording of interactions for coaching? Recordings stay confidential and are used only for treatment. *

YesNo

Concerns about participating in coached sessions

Other services of interestEMDR for trauma processingFamily or reunification therapyMarriage / relationship counselingIndividual counseling for a parent

Emergency contact name *

Emergency contact phone *

Primary care physician

Physician phone

Current or previous therapists (include contact if you want records requested)

Insurance provider

Policy / ID number

Subscriber name

How did you hear about these PCIT services?

Consent and signatures

This information is used only for treatment planning. PCIT focuses on strengthening the parent-child relationship through positive interaction skills and effective discipline. A second caregiver may sign if that person will participate.

I give permission for Jason Cheney, LPC to use this information in PCIT treatment planning and I agree to the terms above. *

Parent / caregiver 1 typed name *

Date *

Parent / caregiver 1 signature *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Typed legal nameI agree that typing my name is my electronic signature. It has the same legal effect as signing on paper under the federal ESIGN Act and the Colorado Uniform Electronic Transactions Act.

Parent / caregiver 2 typed name (if participating)

Parent / caregiver 2 date

Parent / caregiver 2 signature

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Sign by typing your legal name and checking the consent box, then submit the form.

26 required items are still blank, including “I have read this description and understand PCIT is a live-coached parenting skills program.”. You can still press Submit — the next screen will say exactly what is missing.

PCIT Intake Paperwork and Statement of Understanding

What PCIT is

When PCIT is court-involved

Caregiver and household information

Child information

Reason for seeking PCIT

Developmental, medical, and family history

Coaching, contacts, and insurance

Consent and signatures