REGISTRATION: APA Psychotherapy Caucus Meet and Greet "Post-residency Psychotherapy Training", Th 11/02/2023

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This information will be summarized in a Meeting Registrant Directory for distribution to meeting registrants, unless you request otherwise at the bottom of this form. The meeting link will be sent via email to registrants the week of the meeting.

Email *

Your First Name *

Your Last Name *

Your title and training/career stage (MS medical student, PGY post-graduate year, ECP early career psychiatrist) *

MS1/MS2

MS3/ MS4 +

MD/DO or recognized international equivalent, residency applicant or PGY1/2

MD/DO or recognized international equivalent, PGY3/4 +

MD/DO or recognized international equivalent, ECP (<7 years post-training completion)

MD/DO or recognized international equivalent, >7 years post-training completion

Would you consider yourself a potential mentor, or a potential mentee, on this meeting's topic? *

Mentor

Mentee

Neither, or prefer not to state

(Optional) Please provide your phone number, email address, or other contact information you would like to share with meeting registrants. NB: your email address will NOT be shared unless you include it in your answer to this question, so please re-enter it if you would like it shared.

Which APA District Branch are you a part of (e.g., State Psychiatric Society), or what is the primary geographic location of your practice? *

What is/are your primary practice setting(s)? *

Community mental health

Consult liaison

Emergency

Inpatient psychiatry

Outpatient psychiatry clinic or department

Private practice

Residential

Substance treatment

Prefer not to state

Other:

Required

What is/are your primary patient populations? *

Adult

Children/adolescents

Prefer not to state

Other:

Required

Opt OUT from post-meeting messages from the Mentoring Workgroup about additional educational resources (e.g., articles, workshops, conferences) related to this topic

No, please do not include me in post-meeting messages from the Mentoring Workgroup about this topic

POTENTIAL MENTORS ONLY (mentees, please skip this question): I may be available for mentoring individuals or groups separately from this meeting, and would like to be identified as such in the Meeting Registrant Directory. Potential mentees from this meeting may contact me to discuss the possibility of mentorship.

Yes, I may be available for mentoring individuals or groups separately from this meeting.

Opt OUT from Meeting Registrant Directory

No, please do not include me in the Meeting Registrant Directory that will be distributed to meeting registrants. If I opt out, I understand that, although I am registered for the meeting, I will not receive a copy of the Meeting Registrant Directory.

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