Registration: Central Regional Dinner and CME Presentation: November 18, 2026 Survey

1.Demographics(Required.)

First Name

Last Name

Credentials (MD, DO, APN, PA, etc.)

Practice/Organization Name

Practice County

Email Address

Phone Number

2.NPI Number (if not applicable, please write "NA")(Required.)

3.Please indicate if you are an attending or a medical resident at your practice:(Required.)

Attending

Resident

Other (please specify your position)

4.Are you a member of the New Jersey Pediatric Psychiatry Collaborative (NJPPC)?

Not a member? Find a link to the registration form at the end of the survey.(Required.)

I am a NJPPC member

I am not a NJPPC member

Unsure if I am a NJPCC

5.What questions do you have for our presenters on the topic of pediatric developmental concerns vs psychiatric concerns?

6.Do you have any questions for our Physician Champion on how they integrate mental health care and/or work with the NJPPC in their practice?

7.Are you a member of the New Jersey Chapter of the American Academy of Pediatrics? (Please note, this is a separate membership from the national American Academy of Pediatrics)(Required.)

I am an NJAAP member

I am not an NJAAP member

Unsure if I am an NJAAP

8.Please select your entrée for the evening.
To assist with our final meal count, please note that your entrée selection is final and cannot be changed.(Required.)

Chicken: Panko Crusted Chicken Rollatini Stuffed with Asiago Cheese & Cremini Mushrooms Topped with Port Wine Gravy served with Roasted Potatoes & Chef's Vegetable Selection, Rolls and Butter

Fish: Pan Seared Atlantic Salmon with Horseradish Crust Topped with Dijon Sauce served with Roasted Potatoes & Chef's Vegetable Selection, Rolls and Butter

Gluten-Free: Grilled Chicken served with Steamed Broccoli and Baked Potato

Vegan/Vegetarian: Grilled Veggie Stack

Certified Kosher Meal: please check your email for more information as the event gets closer

9.Do you require any special accommodations or is there anything else you would like us to know (e.g., food allergies)?

Not a NJPPC member? Register here!