By completing this form, you are registering to attend the NY Public Psychiatry Conference on "The Dignity of Risk: Balancing Professional Responsibility with Recovery-Oriented Principles"  at Mount Sinai West (Roosevelt) Hospital. The keynote speaker will be Larry Davidson, PhD, Director, Yale Program for Recovery and Community Health.

This conference will take place on Friday. April 8, 2016, from 8:45 am to 12:30 pm, with breakfast starting at 8:15 am. The registration fee is $15, to be paid through PayPal (see instructions at bottom of this form, including option to request reduced fee) and payment of the fee will confirm your registration. Attendance is limited to 120 participants so we encourage you to register as early as possible.

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* 1. What is your name?

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* 2. What is your e-mail address?

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* 3. What is the name of the organization with which you are affiliated? If you are not affiliated with any organization, please enter "none".

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* 4. Which of the following best categorizes your position in that organization?

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* 5. What is the highest level of education you have attained?

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* 6. Do you hold any of the following professional licenses or certifications?

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CASAC, CASAC-T
CPS, CPP
Licensed Clinical Social Worker
Licensed Mental Health Counselor
Licensed Practical Nurse
Licensed Psychologist
Medical License
Registered Nurse

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* 7. Which of following best describes the work you are currently doing?

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* 8. How did you find out about this conference?

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* 9. Do you have any suggestions for topics for next year's conference?

To complete registration for this conference, you will be sent a PayPal invoice at the email address that you have provided. Please note that we do not have the facility to send you a PayPal request automatically, so it may take 2-4 days before you receive the request.  Once you receive this email, please click on the secure link to process your payment. Your conference registration will be confirmed once payment is received.

 If you would like to request a reduced fee due to financial hardship, please click on the submit button, and then e-mail your request to Jules Ranz at jmr1@columbia.edu

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