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Community Based Behavioral Health Crisis Intervention (9.58) Training Registration

Thank you for your interest in the Community Based Crisis Intervention Training. Please complete the short registration form. For questions, please email 958Training@health.nyc.gov.
1.First Name(Required.)
2.Last Name(Required.)
3.Email(Required.)
4.Provider Agency – if your agency is not listed, select ‘Other’ and enter your agency’s name.(Required.)
5.Program Type.(Required.)
6.Are you a physician or a qualified mental health professional?(Required.)
7.Verification of Employment (such as a copy of current employment ID)(Required.)
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8.Verification Letter of Role on a Mobile Team (a letter on business letterhead with name and approval by supervisor)(Required.)
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9.New York State Identification (for example, NYS drivers license, Enhanced or REAL ID, passport)(Required.)
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10.Verification of NYS Department of Education Registered License (such as a copy of current registration of license listed in the Office of Professions by the State Department of Education)(Required.)
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11.Is this your first time attending the training or are you renewing your designation?(Required.)