Email*

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Field of Work, Discipline, Agency*

Do you currently (or have you in the past):*

Provide direct service to infants, young children and their families
Provide supervision for staff that are working with infants, young children and their families
In a position of leadership at an agency/organization that works on behalf of infants, young children and their families

Are you interested in receiving Continuing Education Credit for one of the following licenses:*

Are you interested in pursuing Infant Mental Health Endorsement through The New York State Association for Infant Mental Health*

Have/do you received Reflective Supervision (currently or in the past)*

Have you received training or consultation in Reflective Supervision?*

Tell us a bit about why you are interested in participating in this training.

Anything else that is useful for us to know or be aware of?

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To report suspected child abuse or neglect, please call Monroe Co. Child Protective Services (CPS) at 1-800-342-3720.