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.

Question Title

* 1. Is this your first time attending the training or are you renewing your designation?

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. Email

Question Title

* 5. Provider Agency – if your agency is not listed, select ‘Other’ and enter your agency’s name.

Question Title

* 6. Program Type – if your program type is not listed, select ‘Other’ and enter your program’s type.

Question Title

* 7. Are you a physician or a qualified mental health professional?

Question Title

* 8. Verification of Employment (such as a copy of current employment ID)

Question Title

* 9. Verification Letter of Role on a Mobile Team (a letter on business letterhead with name and approval by supervisor)

Question Title

* 10. New York State Identification (for example, NYS drivers license, Enhanced or REAL ID)

Question Title

* 11. 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)

T