New Jersey Pediatric Psychiatry Collaborative Registration

Please select from the following: *

I have read the information about the NJPPC online and would like to register for the PPC Hub. As such, I understand that someone from NJAAP or the PPC Hubs will reach out to me at my practice to schedule a mandatory Orientation Office Visit for training and on-boarding purposes.

In addition to the NJPPC Hub, I am interested in learning more about NJAAP's Mental Health Virtual Learning Collaboratives, awarding CME credits and MOC part 2 points.

I would like to learn more about the NJPPC Hub’s telepsychiatry enhancement (you will be contacted by a member of our telepsychiatry team).

Practice Name *

Your Name *

Designation (MD, APN, etc) *

Email Address (Note: This should be a secure work email address that you feel comfortable receiving patient updates through and check regularly.) *

Provider NPI #

Practice NPI #

Office Manager/Supporting Team Member Name *

Office Manager/Supporting Team Member Email Address *

Practice Address *

Practice Address

City

State/Province

Zip/Postal

Country

How many staff members are in your practice? If you works at a group-based clinic or large facility (eg., medical school or hospital), please provide the staffing numbers in your workgroup.

Practice County (Check all that apply) *

Screening data submission primary contact (PPC participating physician/provider) for weekly data submission and reminders: Enter your preferred email address for screening log submission: *

Screening data submission secondary contact (to be copied on emails) - Name & Email

Practice Phone Number *

Practice Fax Number *

Practice Email *

Practice Website/URL

Best time to reach you by phone

Best number to reach you *

How comfortable are you at each stage within the continuum of mental/behavioral health medication management? Note: One of the goals of this program is to increase your comfort with management of non-complicated diagnoses without additional comorbidities. Your Regional Hub is always available to support you with patient care management. *

What mental/behavioral health screening tools are you utilizing for well-child visits?

Why are you interested in joining the NJPPC?

Name & email of other providers in your office interested in receiving more information:

How did you hear about the New Jersey Pediatric Psychiatry Collaborative? (Check all that apply)

What Racial/Ethnic group do you identify with?

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latinx/o/a

Native Hawaiian or Pacific Islander

White, not Hispanic or Latinx/o/a

Prefer not to respond

A race/ethnicity not listed here

What language(s) do you and does your practice team speak? Check all that apply.