American Psychiatric Association Foundation

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Please complete the registration information below. Your username will be your email address. Once you submit your registration, you will receive a confirmation email from fellowships@psych.org. Be sure to check your Spam folder if you do not see the confirmation in your Inbox. Required information is marked with an asterisk.

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Current City

Current State

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Demographics

To assess our efforts regarding equal opportunity and affirmative action, APAF tracks ethnicity, sexual orientation, and gender status. The completion of this section is voluntary.

Which of the following best describes your current gender identity?
(Mark all that apply)

Man	Woman
Transgender woman/Male-to-Female (MTF)	Transgender man/Female-to-Male (FTM)
Non-binary	Genderqueer
Another (Please specify below)

Please specify if another

Which of the following do you consider yourself to be?
(Please choose one)

Please specify if another

Race
(Check all that apply)

American Indian or Alaska Native	Asian
Black or African American	Native Hawaiian or Pacific Islander
White	Other

Please specify if other

Are you Spanish, Hispanic or Latino?
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Alumni Directory Access

Are you a current APA Foundation Fellow or Alumni and want to request access to view the Alumni Directory?
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Fellowship Details

What APA/APAF Fellowship did you receive?

If Other, please specify

What year did you start the Fellowship?

Last Name when you started the Fellowship

Did you receive more than one Fellowship?
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Please indicate the second Fellowship you received

If Other, please specify

What year did you start the second Fellowship?

Would you like to add another Fellowship details that you received?
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Please indicate the third Fellowship you received

If Other, please specify

Visibility on Alumni Directory

Hide your profile from other users on Alumni Directory?
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Education Details

Residency Training Institution

City

State

Country

Year of Completion

Clinical Fellowship

Fellowship Institution

City

State

Year of Completion

Board Certifications

Certification Board

American Board of Psychiatry and Neurology	American Board of Allergy and Immunology
American Board of Anesthesiology	American Board of Colon and Rectal Surgery
American Board of Dermatology	American Board of Emergency Medicine
American Board of Family Medicine	American Board of Internal Medicine
American Board of Medical Genetics and Genomics	American Board of Neurological Surgery
American Board of Nuclear Medicine	American Board of Obstetrics and Gynecology
American Board of Ophthalmology	American Board of Orthopaedic Surgery
American Board of Otolaryngology - Head and Neck Surgery	American Board of Pathology
American Board of Pediatrics	American Board of Physical Medicine and Rehabilitation
American Board of Plastic Surgery	American Board of Preventive Medicine
American Board of Radiology	American Board of Surgery
American Board of Thoracic Surgery	American Board of Urology

Please choose sub speciality for American Board of Psychiatry and Neurology
(Select all that apply)

Addiction Psychiatry	Brain Injury Medicine
Child and Adolescent Psychiatry	Clinical Neurophysiology
Consultation-Liaison Psychiatry	Epilepsy
Forensic Psychiatry	Geriatric Psychiatry
Neurocritical Care	Neurodevelopmental Disabilities
Neuromuscular Medicine	Pain Medicine
Sleep Medicine	Vascular Neurology

Please choose sub speciality for American Board of Anesthesiology
(Select all that apply)

Adult Cardiac Anesthesiology	Critical Care Medicine
Hospice and Palliative Medicine	Neurocritical Care
Pain Medicine	Pediatric Anesthesiology
Sleep Medicine

Please choose sub speciality for American Board of Dermatology
(Select all that apply)

Dermatopathology	Micrographic Dermatologic Surgery
Pediatric Dermatology

Please choose sub speciality for American Board of Emergency Medicine
(Select all that apply)

Anesthesiology Critical Care Medicine	Emergency Medical Services
Hospice and Palliative Medicine	Internal Medicine-Critical Care Medicine
Medical Toxicology	Neurocritical Care
Pain Medicine	Pediatric Emergency Medicine
Sports Medicine	Undersea and Hyperbaric Medicine

Please choose sub speciality for American Board of Family Medicine
(Select all that apply)

Adolescent Medicine	Geriatric Medicine
Hospice and Palliative Medicine	Pain Medicine
Sleep Medicine	Sports Medicine

Please choose sub speciality for American Board of Internal Medicine
(Select all that apply)

Adolescent Medicine	Adult Congenital Heart Disease
Advanced Heart Failure and Transplant Cardiology	Cardiovascular Disease
Clinical Cardiac Electrophysiology	Critical Care Medicine
Endocrinology, Diabetes and Metabolism	Gastroenterology
Geriatric Medicine	Hematology
Hospice and Palliative Medicine	Infectious Disease
Interventional Cardiology	Medical Oncology
Nephrology	Neurocritical Care
Pulmonary Disease	Rheumatology
Sleep Medicine	Sports Medicine
Transplant Hepatology

Please choose sub speciality for American Board of Medical Genetics and Genomics
(Select all that apply)

Clinical Biochemical Genetics	Clinical Genetics and Genomics (MD)
Laboratory Genetics and Genomics	Medical Biochemical Genetics
Molecular Genetic Pathology

Please choose sub speciality for American Board of Neurological Surgery
(Select all that apply)

Neurocritical Care

Please choose sub speciality for American Board of Obstetrics and Gynecology
(Select all that apply)

Complex Family Planning	Critical Care Medicine
Female Pelvic Medicine and Reconstructive Surgery	Gynecologic Oncology
Maternal–Fetal Medicine	Reproductive Endocrinology and Infertility

Please choose sub speciality for American Board of Orthopaedic Surgery
(Select all that apply)

Orthopaedic Sports Medicine

Surgery of the Hand

Please choose sub speciality for American Board of Otolaryngology – Head and Neck Surgery
(Select all that apply)

Complex Pediatric Otolaryngology	Neurotology
Plastic Surgery Within the Head and Neck	Sleep Medicine

Please choose sub speciality for American Board of Pathology
(Select all that apply)

Pathology – Anatomic	Pathology - Clinical
Blood Banking/Transfusion Medicine	Clinical Informatics
Cytopathology	Dermatopathology
Hematopathology	Neuropathology
Pathology – Chemical	Pathology – Forensic
Pathology – Medical Microbiology	Pathology – Molecular Genetic
Pathology – Pediatric

Please choose sub speciality for American Board of Pediatrics
(Select all that apply)

Adolescent Medicine	Child Abuse Pediatrics
Developmental-Behavioral Pediatrics	Hospice and Palliative Medicine
Medical Toxicology	Neonatal-Perinatal Medicine
Pediatric Cardiology	Pediatric Critical Care Medicine
Pediatric Emergency Medicine	Pediatric Endocrinology
Pediatric Gastroenterology	Pediatric Hematology-Oncology
Pediatric Hospital Medicine	Pediatric Infectious Diseases
Pediatric Nephrology	Pediatric Pulmonology
Pediatric Rheumatology	Pediatric Transplant Hepatology
Sleep Medicine	Sports Medicine

Please choose sub speciality for American Board of Physical Medicine and Rehabilitation
(Select all that apply)

Brain Injury Medicine	Neuromuscular Medicine
Pain Medicine	Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine	Sports Medicine

Please choose sub speciality for American Board of Plastic Surgery
(Select all that apply)

Plastic Surgery Within the Head and Neck

Surgery of the Hand

Please choose sub speciality for American Board of Preventive Medicine
(Select all that apply)

Aerospace Medicine	Occupational Medicine
Public Health and General Preventive Medicine	Addiction Medicine
Clinical Informatics	Medical Toxicology
Undersea and Hyperbaric Medicine

Please choose sub speciality for American Board of Radiology
(Select all that apply)

Diagnostic Radiology	Interventional Radiology and Diagnostic Radiology
Medical Physics (Diagnostic, Nuclear, Therapeutic)	Radiation Oncology
Neuroradiology	Nuclear Radiology
Pain Medicine	Pediatric Radiology

Please choose sub speciality for American Board of Surgery
(Select all that apply)

General Surgery	Vascular Surgery
Complex General Surgical Oncology	Pediatric Surgery
Surgery of the Hand	Surgical Critical Care

Please choose sub speciality for American Board of Thoracic Surgery
(Select all that apply)

Please choose sub speciality for American Board of Urology
(Select all that apply)

Female Pelvic Medicine and Reconstructive Surgery

Pediatric Urology

My Practice

Specialty Focus

ADHD (Adult)	ADHD (Child)
Adjustment Disorders	AIDS/HIV
Alcohol/Substance Abuse Treatment	Anxiety/Panic/Phobic Disorders
Autism/Pervasive Developmental Disorders	Childhood Behaviour Disorders
Delirium/Dementia/Other Cognitive Disorders	Dissociative Disorders
Eating Disorders	Family, Couple, Relational Problems
I don't treat patients	Impulse Control Disorders (gambling, kleptomania)
Interpersonal Violence and Abuse	Learning Disorders
Medical/Psychiatric Disorders	Mental Retardation/Developmental Disabilities
Mood Disorders	Movement Disorders
Obsessive-Compulsive Disorders	Pain Disorders
Personality Disorders	Post-Traumatic Stress Disorder
Schizophrenia and Psychotic Disorders	Sexual Disorders/paraphilias
Sleep Disorders/Polysomnography/Sleep Lab	Somatoform Disorders
Suicide/Self-Injury/Aggressive Behavior	Traumatic Brain Injury
Other

If other, please specify

Patient Specialty

Adolescents	Adults
Children	Geriatric Adults
I dont treat patients

Work Schedule

Full time psychiatry	Currently practicing another medical specialty
Part time psychiatry	Fully Retired
Partially Retired

Main Roles

Administration	Consultation
Direct Patient Care	Research
Teaching	Private Practice
Other

If other, please specify

Research Details

Research Interests

Remaining 1000 words out of 1000

SAMHSA MFP Fellows

Please indicate the title of your project

Please describe your SAMHSA project

Remaining 1000 words out of 1000

Mentoring Opportunities

Are you interested in mentoring a current APA/APAF Fellow?
Yes No

If yes, do you prefer a formal or informal mentoring relationship?
Formal Informal

If you are a current Fellow, are you interested in having an alumni mentor?
Yes No

If yes, do you prefer a formal or informal mentoring relationship?
Formal Informal

APA / APAF Leadership Engagement

Please indicate your current and past involvement in APA / APAF Leadership positions
(Select all that apply)

APA Foundation Board of Directors	APA Board of Trustees
APA Assembly	APA Councils
APA Committees	District Branch & State Association
Other

Please update the Leadership position if you selected Other

Please select the APA Council.
(Select all that apply)

Council on Addiction Psychiatry	Council on Advocacy and Government Relations
Council on Children, Adolescents and Their Families	Council on Communications
Council on Geriatric Psychiatry	Council on Healthcare Systems and Financing
Council on International Psychiatry	Council on Medical Education and Lifelong Learning
Council on Minority Mental Health and Health Disparities	Council on Psychiatry and Law
Council on Psychosomatic Medicine (Consulation Liason Psychiatry)	Council on Quality Care
Council on Research	Ethics Committee

Please select if you are a current or former member for Council on Addiction Psychiatry
Current Member Former Member

Please select if you are a current or former member for Council on Advocacy and Government Relations
Current Member Former Member

Please select if you are a current or former member for Council on Children, Adolescents and Their Families
Current Member Former Member

Please select if you are a current or former member for Council on Communications
Current Member Former Member

Please select if you are a current or former member for Council on Geriatric Psychiatry
Current Member Former Member

Please select if you are a current or former member for Council on Healthcare Systems and Financing
Current Member Former Member

Please select if you are a current or former member for Council on International Psychiatry
Current Member Former Member

Please select if you are a current or former member for Council on Medical Education and Lifelong Learning
Current Member Former Member

Please select if you are a current or former member for Council on Minority Mental Health and Health Disparities
Current Member Former Member

Please select if you are a current or former member for Council on Psychiatry and Law
Current Member Former Member

Please select if you are a current or former member for Council on Psychosomatic Medicine (Consulation Liason Psychiatry)
Current Member Former Member

Please select if you are a current or former member for Council on Quality Care
Current Member Former Member

Please select if you are a current or former member for Council on Research
Current Member Former Member

Please select if you are a current or former member for Ethics Committee
Current Member Former Member

Please select the APA Committees.
(Select all that apply)

Committee on Advocacy and Litigation Funding	Committee on Reimbursement for Psychiatric Care
Committee on Telepsychiatry	Committee on RBRVS, Codes and Reimbursement
Committee on Integrated Care	Committee on Innovation
Vestermark Award Committee	Committee on Well-Being and Burnout
Scientific Program Committee (APA Annual Meeting & IPS/Mental Health Services Conference)	Committee on Judicial Action
Committee on Mental Health IT	Committee on Quality and Performance Measurement
Committee on Practice Guidelines	Committee on Psychiatric Dimensions of Disaster
Committee on Climate Change and Mental Health	Other

If Other, please describe

Please select if you are a current or former member for Committee on Advocacy and Litigation Funding
Current Member Former Member

Please select if you are a current or former member for Committee on Reimbursement for Psychiatric Care
Current Member Former Member

Please select if you are a current or former member for Committee on Telepsychiatry
Current Member Former Member

Please select if you are a current or former member for Committee on RBRVS, Codes and Reimbursement
Current Member Former Member

Please select if you are a current or former member for Committee on Integrated Care
Current Member Former Member

Please select if you are a current or former member for Committee on Innovation
Current Member Former Member

Please select if you are a current or former member for Vestermark Award Committee
Current Member Former Member

Please select if you are a current or former member for Committee on Well-Being and Burnout
Current Member Former Member

Please select if you are a current or former member for Scientific Program Committee (APA Annual Meeting & IPS/Mental Health Services Conference)
Current Member Former Member

Please select if you are a current or former member for Committee on Judicial Action
Current Member Former Member

Please select if you are a current or former member for Committee on Mental Health IT
Current Member Former Member

Please select if you are a current or former member for Committee on Quality and Performance Measurement
Current Member Former Member

Please select if you are a current or former member for Committee on Practice Guidelines
Current Member Former Member

Please select if you are a current or former member for Committee on Psychiatric Dimensions of Disaster
Current Member Former Member

Please select if you are a current or former member for Committee on Climate Change and Mental Health
Current Member Former Member

Please select if you are a current or former member for other
Current Member Former Member

Contact Us

American Psychiatric Association
800 Maine Avenue, S.W., Suite 900
Washington, DC 20024
Email: samhsamfp@psych.org