By completing this form, you are registering to attend the NY Public Psychiatry Conference on "“(Re)building Strong Foundations: Trauma Informed Care  in Public Mental Health"  at Mount Sinai West (Roosevelt) Hospital. The speakers, Paula Panzer and Jacob Ham,  will be followed by a panel of 5 discussants including the two speakers plus Tony Solerno,  Anne Tallegrand and Susan Albamont. 

This conference will take place on Friday. April 21, 2017, from 8:45 am to 12:30 pm, with breakfast starting at 8:15 am. The registration fee is $15 to be paid through PayPal (see instructions at bottom of this form, including option to request reduced fee) and payment of the fee will confirm your registration. Attendance is limited to 120 participants so we encourage you to register as early as possible.

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* 1. What is your name?

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* 2. What is your e-mail address?

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* 3. Re-enter your e-mail address

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* 4. What is your phone number?

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* 5. What is the name of the organization with which you are affiliated? If you are not affiliated with any organization, please enter "none".

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* 6. Which of the following best categorizes your position in that organization?

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* 7. What is the highest level of education you have attained?

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* 8. Do you hold any of the following professional licenses or certifications? Check all that apply

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* 9. How did you find out about this conference? Check all,that apply. 

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* 10. Do you have any suggestions for topics for next year's conference?

To complete registration for this conference, you will be sent a PayPal invoice at the e-mail address that you have provided. Please note that we do not have the ability to  send you a PayPal request automatically, so it may take 2-4 days before you receive this invoice. Once you receive this e-mailed invoice, please click on the secure link in that e-mail to process your payment. Your conference registration will be confirmed once payment is received.

 If you would like to request a reduced fee due to financial hardship, please click on the submit button, and then e-mail your request to Jules Ranz at jmr1@columbia.edu

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