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Registration Details
Education and Professional Interests
APA / APAF Engagements

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Contact Information

First Name*

Last Name*

Middle Name

Phone Number

Current City

Current State

Current Country

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?
Yes No

Alumni Directory Access

Are you a current APA Foundation Fellow or Alumni and want to request access to view the Alumni Directory?
Yes No

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?
Yes No

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?
Yes No

Please indicate the third Fellowship you received

If Other, please specify

Visibility on Alumni Directory

Hide your profile from other users on Alumni Directory?
Yes No

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

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Email: fellowships@psych.org