Reflective Supervision Training Contact List

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):*

Work with infants, young children and their families
Have responsibility for teaching, training, coaching or mentoring human service professionals
Work on policy and/or systems that impact infants, young children and their families
Do research that has a focus on infants, young children and their families
Work 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)*

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?