MFLWL Check-In Participation Form
For each Check-In session, this form is used to track WHO is present for part or all of Check-In, who presents a MFLWL call, and who participates in a structured Role-Play.
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Adresse e-mail *
Date of Check-In *
JJ
/
MM
/
YYYY
Faculty Supervising This Check-In Session
Please use Volunteer/Faculty Nicknames as per the list below. If you don't see the name, please enter the full name in the Other slot for the Question.
Ann Hartman LCSW: AnnH
Adolphe Wakana: AdolpheW
Barbara Loewenberg-Irlandy LCSW: BarbaraLI
Brian Englander LCSW, LADC: BrianE
Colleen Owens LCPC: ColleenO
Constance Jordan ANP, PMHNP: ConnieJ
Dara Saffer LCSW: DaraS
Decha Bailey LCSW: DechaB
Dianna Poulin: DiannaP
Donna Beeley BS, MEd, CAS: DonnaB
Edward Pontius MD: EdP
Eileen Fair LCSW: EileenF
Elaine Piecuch LCSW: ElaineP
Ellen Grunblatt MD, LCPC: EllenG
Gary McGrane: GaryT
Holly Donovan LCSW, CADC: HollyD
Janis Petzel MD: JanisP
Jesse Higgins MSN, PMHNP: JesseMH
Joe (George) Dreher MD: JoeD
Julie Johnson LCSW: JulieJ
Karen Gersen LCSW: KarenG
Karen Ryla LCPC, NCC: KarenR
Katie Campbell LCSW: KatieC
Kristine Wing MEd, LSC: KrisW
Lani Graham MD, MPH: LaniG
Laura Watters LCPC: LauraW
Leigh Haskell PhD: LeighH
Linda Cooke MSW, LCSW, BCD: LindaC
Lindan Andrews LCSW: LindanA
Loida Ruane LCSW: LoidaR
Louisa Barnart MD: Louisa B
Marianne Tarraza PMH-NP: MarianneT
Mark Rains PhD: MarkR
Mark Simmons LCPC CADC: MarkS
Paula Marcus-Platz LCSW: PaulaMP
Pia Marancik  Ph.D.: PiaM
Poppy Connor-Crouch LCSW: PoppyCC
Richard Lewis LCPC: RLewisLCPC
Susan Soverel MSW: SusanS
Susan Weiss School Counselor: SusanW
Susan Peixotto LCSW: SusieP
Tara LiBrizzi LCSW: TaraL
Tracy  Riggins LCSW: TracyR
Wendy Noyes LCPCC: WendyBeth
Please check the box for participants at this Check-In. Please be sure to record a check for those participants presenting a call or participating in a structured Role-Play exercise.
Participated in Check-In
Presented MFLWL Call
Participated in Role-Play Exercise
Ann Hartman LCSW: AnnH
Adolphe Wakana: AdolpheW
Barbara Loewenberg-Irlandy LCSW: BarbaraLI
Brian Englander LCSW, LADC: BrianE
Colleen Owens LCPC: ColleenO
Constance Jordan ANP, PMHNP: ConnieJ
Dara Saffer LCSW: DaraS
Decha Bailey LCSW: DechaB
Dianna Poulin: DiannaP
Donna Beeley BS, MEd, CAS: DonnaB
Edward Pontius MD: EdP
Eileen Fair LCSW: EileenF
Elaine Piecuch LCSW: ElaineP
Ellen Grunblatt MD, LCPC: EllenG
Gary McGrane: GaryT
Holly Donovan LCSW, CADC: HollyD
Janis Petzel MD: JanisP
Jesse Higgins MSN, PMHNP: JesseMH
Joe (George) Dreher MD: JoeD
Julie Johnson LCSW: JulieJ
Karen Gersen LCSW: KarenG
Karen Ryla LCPC, NCC: KarenR
Katie Campbell LCSW: KatieC
Kristine Wing MEd, LSC: KrisW
Lani Graham MD, MPH: LaniG
Laura Watters LCPC: LauraW
Leigh Haskell PhD: LeighH
Linda Cooke MSW, LCSW, BCD: LindaC
Lindan Andrews LCSW: LindanA
Loida Ruane LCSW: LoidaR
Louisa Barnart MD: Louisa B
Marianne Tarraza PMH-NP: MarianneT
Mark Rains PhD: MarkR
Mark Simmons LCPC CADC: MarkS
Paula Marcus-Platz LCSW: PaulaMP
Pia Marancik Ph.D.: PiaM
Poppy Connor-Crouch LCSW: PoppyCC
Richard Lewis LCPC: RLewisLCPC
Susan Soverel MSW: SusanS
Susan Weiss School Counselor: SusanW
Susan Peixotto LCSW: SusieP
Tara LiBrizzi LCSW: TaraL
Tracy Riggins LCSW: TracyR
Wendy Noyes LCPCC: WendyBeth
Anyone else at Check-In NOT on list above? Please type in name, and (C) if person presented a call, (RP) if person participated in role-play.
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