Customize Your FAIMH Communications

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete the following questions to help us tailor our communication to you so that you receive the information that is most valuable to you.

First Name
*

Last Name
*

Email
*

Cell Phone Number *

Are you a current FAIMH member? *

Yes

Are you currently a member of a Local FAIMH Chapter?

Yes

In what county do you live and/or work?
*

Select the FAIMH Chapter that you belong to, OR the Chapter that is closest to where you live and/or work.

Tell us about yourself.

I am a supporter of FAIMH but do not work with Infants, young children and/or their families.

I work with, or on behalf of, infants, young children, or their families.

What field/discipline do you work in? *

Early Learning/Child Care

Early Head Start

Early Intervention

Education Resources, Family Support, Parent Education

Mental Health or Social Work

Pediatric Healthcare (Pediatricians, Nurses)

Pediatric Allied Healthcare (Speech-Language, Occupational, Physical Therapy)

Psychiatry

Higher Education (university faculty or staff)

Other:

What organization do you current work for?
*

What position do you hold? *

Direct Service Staff (working directly with children 0-5 or their families)

Support Staff (working to support a program that serves children 0-5 or their families)

Manager/Supervisor (manages or supervises a team of direct service staff)

Leadership (serves as an administrator, director or executive of a program/organization that serves children 0-5 or their families)

Other:

These categories reflect the various scopes of practice of an Infant Mental Health Professional. Use this image to find what you believe is your best-fit category. Having this information will allow us to best tailor our communications to your needs and interests.

Based on the image above, do you align with the Infant Family categories (Infant Family Associate or Infant Family Specialist), or the Infant Mental Health categories (Infant Mental Health Specialist or Mentor)?

I best fit the Infant Family categories (Infant Family Associate or Infant Family Specialist)

I best fit the Infant Mental Health categories (Infant Mental Health Specialist or Mentor)

I do not fit a category; I am a friend of FAIMH but not an IMH professional

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Florida Association for Infant Mental Health (FAIMH). Report Abuse

Forms