PEPPNET NEW MEMBER FORM Thank you for your interest in joining the PSYCHOSIS-RISK AND EARLY PSYCHOSIS PROGRAM NETWORK (PEPPNET). Your responses on this brief form will help us better understand our growing membership and allow us to develop a structure and services that appropriately meet the diverse interests and skills represented. Question Title * 1. Please enter your name and contact information. Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. Describe your primary role. Clinical Research/Academic Programmatic/Technical Assistance Administrative Advocacy/Public Education Consumer Family Member Other (please specify) Question Title * 3. What do you hope to gain from participating in PEPPNET? Question Title * 4. Were you invited to join the Child and Adolescent (CAP) First Episode Psychosis list serve? (if "yes", please specify by whom) Yes No If yes, please specify who invited you: Question Title * 5. Are you currently working with an early psychosis population in some capacity? Yes No Other (please specify) Next