Project TEACH

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Occupation(Required)

Current clinical credentials

if applicable, e.g. MD, DO, PhD, PsyD, NP, PA, CNM, LICSW, LMFT, etc.

Do you provide clinical services in New York State?(Required)

Yes

which county do you provide clinical services in New York State?

Employer(Required)

Are you currently a student/trainee?(Required)

Yes

what school or placement do you currently attend?

what program are you currently attending?

What degree are you currently attending for?

expected year of graduation?

Reason for Applying(Required)

In less than 500 words, please describe your involvement in perinatal mental health, how long you’ve been involved in this field, and why you are interested in perinatal mental health and participation in this training.

Resume / CV(Required)

Accepted file types: doc, docx, pdf, Max. file size: 2 MB.

Can you provide bilingual and/or bicultural expertise?(Required)

Yes

Some

Have you attended a perinatal mental health training in the past?(Required)

Yes

what perinatal mental health training did you attend?

when did you attended a perinatal mental health training?

Is there anything else you would like the Project TEACH selection committee to know?

How did you learn about Project TEACH perinatal mental health/reproductive psychiatry training scholarships?(Required)

First Choice

Second Choice

Third Choice

Other

If 'Other', please list below

Postpartum Support International (PSI): Perinatal Mental Health Certification Program (PMH-C)