SUNY Downstate Asylum Clinic Training Registration Form

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Thank you for your interest in the SUNY Downstate Asylum Clinic Training on Sunday, November 6th, 2022 from 9 AM - 3 PM! This event will be hosted in the Alumni Auditorium at SUNY Downstate. Please complete this form below, as we will send you more information regarding the event closer to the date.

All Downstate and Kings County affiliated clinicians are encouraged to join the event in-person! Those unaffiliated with Downstate or Kings County must use the Zoom link.

Check out our website for more information about our organization! https://www.downstatephr.com/

Please note this training constitutes a lifetime certification.

ALL DOWNSTATE STUDENTS MUST ATTEND IN-PERSON IN ORDER TO BE ELIGIBLE TO VOLUNTEER.

If you have already completed this training, you do not need to attend again - however, you are welcome to come for all or part of the training to brush up your skills.

Email *

Name *

Please indicate your pronouns

He/Him/His

She/her/hers

They/them/theirs

Other:

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Degree *

MD/DO (Attending)

MD/DO (Resident)

Psychologist (PsyD, PhD)

Licensed Mental Health and/or Social Worker

Medical Student

Nursing Student

Physical Therapy Student

Occupational Therapy Student

Other:

Institution *

Fluent Languages

Specialty (if applicable)

OB/GYN

Psychiatry

Internal Medicine

Family Medicine

Pediatrics

Other:

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How do you plan on attending our event? *

In-person at SUNY Downstate (Downstate or Kings County affiliates ONLY)

Zoom

Food Preferences (If any)

Kosher

Vegetarian

Vegan

Other:

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