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New Jersey Pediatric Psychiatry Collaborative Registration
NJPPC Membership Registration Form
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" indicates required fields
Please select from the following:
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I have read the information about the NJPPC online and would like to register for the NJPPC. As such, I understand that someone from NJAAP or the NJPPC Regional Hubs will reach out to me to schedule a mandatory orientation session for training and onboarding purposes.
In addition to the NJPPC membership, 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 Telepsychiatry Enhancement (you will be contacted by a member of our telepsychiatry team).
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Please select from the following:
I have read the information about the NJPPC online and would like to register for the NJPPC. As such, I understand that someone from NJAAP or the NJPPC Regional Hubs will reach out to me to schedule a mandatory orientation session for training and onboarding purposes.
In addition to the NJPPC membership, 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 Telepsychiatry Enhancement (you will be contacted by a member of our telepsychiatry team).
Practice Name
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Your Name
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Designation (MD, APN, etc)
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Email Address
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(Note: This should be a secure work email address that you feel comfortable receiving patient updates through and check regularly.)
Cell Phone Number
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(This will be utilized by NJPPC Regional Hub staff and Child and Adolescent Psychiatrists for patient consults.)
Practice Phone Number
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Practice Fax Number
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Provider NPI #
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Practice NPI #
Office Manager/Supporting Team Member Name
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Office Manager/Supporting Team Member Email Address
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Practice Address
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Street Address
City
ZIP / Postal Code
Practice County (Check all that apply)
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Atlantic
Bergen
Burlington
Camden
Cape May
Cumberland
Essex
Gloucester
Hudson
Hunterdon
Mercer
Middlesex
Monmouth
Morris
Ocean
Passaic
Salem
Somerset
Sussex
Union
Warren
Please indicate if you are an attending or a medical resident at your practice.
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Attending
Resident
The NJPPC is open to clinicians who work with pediatric patients. Please indicate your specialty by using the checkboxes below.
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Pediatrics
Family Medicine
Sub-Specialty
I am a PA, APN or NP
You selected 'Sub-Specialty'. Please enter which specialty:
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Why are you interested in joining the NJPPC?
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To better serve patients with mental health issues and for my patients to receive mental health care and resources in a timely manner
I need support/guidance on complicated cases, diagnosis, management, referral, and initiating therapy/treatment
To become confident and comfortable in managing patients with mental health issues
To collaborate with other mental health providers (contact with CAPs)
Providers in my practice have recommended I join the NJPPC
Other
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)
Colleague in my practice
Physician/Practice in my area
New Jersey Pediatrics quarterly publications
Phone Call
Fax
Personal email from NJAAP's Mental Health Collaborative team
NJAAP's email blast
My Regional Pediatric Psychiatry Collaborative Hub
A patient/family
Presentation/Event
Other
Other
(Please specify)
What Racial/Ethnic group do you identify with?
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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
Multiracial or a race/ethnicity not listed here
What language(s) do you and does your practice team speak? Check all that apply.
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Spanish
Chinese (Including Mandarin, Cantonese)
Russian
French
Arabic
Korean
Hindi
Gujarati
Bengali
Portuguese
English Only
Other
Other
(Please Specify)
Once you have completed onboarding and become a member of the NJPPC, you will be added to our provider directory which will include your full name, practice name, practice phone number, and practice location (city/town and county only). The directory will be shared through the NJ Dept. of Children and Families with Care Management Organizations (CMOs) to connect patients without a medical home with an NJPPC-enrolled pediatrician who can best address a child's mental health needs. Please select one of the options below:
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Yes, I do want my enrollment status with the NJPPC added to the directory.
No, I do not want my enrollment status with the NJPPC added to the directory.
Hidden
Once you have completed onboarding and become a member of the NJPPC, you will be added to our provider directory which will include your full name, practice name, practice phone number, and practice location (city/town and county only). The directory will be shared through the NJ Dept. of Children and Families with Care Management Organizations (CMOs) to connect patients without a medical home with an NJPPC-enrolled pediatrician who can best address a child's mental health needs. Please select one of the options below:
Yes, I do want my enrollment status with the NJPPC added to the directory.
No, I do not want my enrollment status with the NJPPC added to the directory.
