Then you for your Conference purchase! Please fill out the form below to complete your Professional Profile. Member Survey Career Level * Graduate student, Intern or Fellow Early Career (<10 yrs from completion of training) Mid/Late Career (>10 yrs) Retired Organization / University * Phone * Address * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other State Zip * Country * United States Other Country Gender (Hold the 'Ctrl' key for multiple selections.) * Man/male Woman/female Transgender Non-binary/Non-conforming Agender Prefer not to answer Other Gender (Hold the 'Ctrl' key for multiple selections.) What are your preferred personal pronouns? What is your Ethnicity? * Hispanic or LatinX: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Non-Hispanic or LatinX Prefer not to answer Hispanic Origin * Mexican or Mexican American Puerto Rican Cuban or Cuban American Other Hispanic, Latino/a, or of Spanish Origin What is Your Race? (Hold the 'Ctrl' key for multiple selections.) * Hispanic or Latino American Indian or Alaskan Native Asian Black or African American Middle Eastern or North African Native Hawaiian or other Pacific Islander White Prefer not to answer Do you have a disability? Individuals with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990, as amended. * Yes, I have a disability. No, I don’t have a disability Prefer not to answer Other Do you have a disability? Individuals with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990, as amended. Are you a military veteran? * Protected Veteran (Special Disabled Veteran, Vietnam Era Veteran, Recently Separated Veteran, Armed Forces Service Medal Veteran, Disabled Veteran) Non-Protected Veteran Not a Veteran Prefer not to answer How did you hear about us? Social Media Colleague APAHC website Internet/search engine APAHC conference Other How did you hear about us? What is the name of your colleague? What is your highest earned psychology degree? * Master’s Degree (MA, MS, MED) Specialist Degree (EDS PsyS, SSP, CABS) Phd PsyD EdD Other What is your highest earned psychology degree? Date Doctorate was Conferred or Graduation Date * (This field requires a format of mm/dd/yyyy.) Work Setting * Hospital Ambulatory Care Facility Child Welfare Facility College/University Counseling/Health Center Correctional Facility Criminal Justice Facility Hospice Independent group practice Independent solo practice Long-term care facility (e.g. nursing home, assisted living) Organization/Business Setting Rehabilitation Residential setting School based mental health service Veterans Facility Medical School Dental School Nursing School Other Work Setting Type of Hospital * Federal Government hospital Non-federal hospital: General Medical Non-federal hospital: Psychiatric Type of Ambulatory Care Facility * Community health center Mental health clinic Primary or specialist medical care Specialized substance abuse treatment facility Leadership Roles Educational leadership roles national or institutional Clinical leadership roles national or institutional Research leadership roles national or institutional OtherOther Are you a Member of the APA? * Yes No Please indicate which national organizations in which you hold a leadership role.(Check all that apply and provide any additional by checking "other.") APA APAPO AAMC CFAS ABPP Training Councils OtherOther Are you a Member of Division 12? * Yes No Please List Any Other Division Memberships Do You Hold a Position In AAMC? * Yes No Please Describe Your Current Involvement with AAMC? * Do You Want To Subscribe to the APAHC Listserve? * Yes No If you are human, leave this field blank. Submit
