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First name:

Last name:

Email address:

Primary organizational affiliation (if applicable):

What is the highest degree (terminal degree) that you hold?:
NoneHigh School DiplomaBS/BAJDMBAMDMPHOther Master'sPhD

What is the setting of your main organizational affiliation?:
Academic Institution / UniversityPrivate Clinical PracticeHealthcare Organization / Health System / HospitalCommunity Mental HealthIndustry / Mental Health Technology CompanyGovernmental AgencyNon-profitHealth Insurer / PayerRegulatory OrganizationPolicy-focused organizationOther (None of the Above)

What is your main professional role?:
Student/TraineeEducator (e.g. faculty, instructor)ResearcherPolicy DeveloperPatient AdvocateAnalyst/Data ScientistClinical Care ProviderOrganizational LeaderComputer Scientist/Developer/EngineerConsumer or CaregiverRegulatory RoleConsultantInvestorOther (None of the Above)

Location:

Are you interested in leadership or committee membership within the society?
YesNo

Is there anything else you would like us to know?:

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