Patient-Centered Mental Health in Pediatric Primary Care (PPP) Registration

Patient-Centered Mental Health in Pediatric Primary Care (PPP) Registration Form

Please use the form below to register for an upcoming PPP program, where you will learn how to assess, diagnose and treat common children's mental health conditions.

Duration: Three-day live course, followed by eight (1 hour) group learning calls

Format: Virtual

Cost: $1,900

The three-day live course follows this schedule: Friday from 12pm - 5.30pm, Saturday from 8.30am - 5pm, and Sunday from 8.30am - 1.30pm. However, please note our courses run in different time zones. To find out the time zone for the course date you have chosen please visit our Upcoming Events page here.

If the dates listed do not work for you, please sign up to be notified of future dates here.

Please note this form is intended for registration of individual participants. To register a group of participants or if you have any questions please email: ppp@thereachinstitute.org

Program Information

Program

Please select the start and end dates of your chosen program.

Start Date

End Date

Contact Information

Salutation

First Name

Last Name

Participant Email

The participant's email address must be entered for registration. All program communications prior to, during, and after the program require responses from the participant directly.

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Phone

Please provide your mailing address below. Mailing address is required in order to receive program materials.

Mailing Country

Mailing Street Address

Mailing State/Province

Mailing City

Mailing Zip/Postal Code

Professional Information

With which license do you practice?

List other/additional licenses

What is your discipline?

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What is your occupation?

Organization/Practice Name

Organization/Practice Country

Organization/Practice Street Address

Organization/Practice City

Organization/Practice State/Province

Organization/Practice Zip/Postal Code

Referral Information

How did you hear about REACH?

If other, please specify how you heard about REACH

Please select social media platform, if applicable

If referred, please specify who referred you:

Referred by (First Name):

Referred by (Last Name):

REACH does not sell or share any personal registration data.

Payment Information

Pre-Discount Total

Payment Amount

Promo Code (if applicable)

Discount Amount

Name on Card

Card Number

Code

Billing Email

Billing Country

Billing Street Address

Billing State/Province

Billing City

Billing Zip/Postal Code

Contact Information

Patient-Centered Mental Health in Pediatric Primary Care (PPP) Registration

Patient-Centered Mental Health in Pediatric Primary Care (PPP) Registration