This form should be completed by school or organization leadership. Once submitted, you will hear back from MHANYS once the form is reviewed. This can take up to one week from completion.

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* 1. Email

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* 2. First and last name of primary contact person:

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* 3. Contact person email:

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* 4. Contact person number:

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* 5. Organization or School Name

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* 6. Organization Address:

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* 7. Is your site a school, youth-serving organization, community behavioral health center, or other? Select all that apply.

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* 8. Is 10% of your adult staff trained in Youth Mental Health First Aid?

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* 9. Is your site willing to have 10%of adult staff trained in Youth Mental Health First Aid?

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* 10. Do you have interest from teens to provide Teen Mental Health First Aid?

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* 11. Where does your site intend to teach or host Teen Mental Health First Aid?

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* 12. Select all that apply to your site.

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* 13. Any other important details we should know about your initiative?

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