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Contact information
First name
*
Last name
*
Email
*
Program Information
Do you have an existing program or are you developing a new program?
*
Existing program
Establishing a new program
Program name, if applicable
Program address, if applicable
If you are establishing a program, please include your location (e.g., city, state, or country outside of the United states).
Date of inception (if applicable)
If your program is not established yet, please include a target time frame for opening.
Program description
Briefly describe the purpose, mission, and philosophy of the program
Number of learners/students served, if applicable
Age range of learners/students served
Diagnosis of learners/students served
Program Leadership
Program director, if applicable
Describe your program director/leadership.
Degrees, certifications, pyears of experience, etc.
Does the program currently have a Board of Trustees?
Yes
No
Are you willing to send a director to PCDI for a 12-month residency to ensure adequate training in the model and the ultimate success of the program and the individuals served within the program?
Yes
No
International Programs
Please fill out this section if your program is located outside of the United States.
Rate English proficiency of program director
Fluent
Proficient
Intermediate
Novice
No English knowledge
If your program director is not fluent or proficient in English, do you have a translator available?
Yes
No
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