Sign Up to Become a Partner

Applicant Information

First Name

Last Name

Job Title

Backup Email

Phone

Street Address

Address Line 2

City

State

Zip Code

Country

If your organization is not listed, share Why be a Mental Health Community Partner Site? with your agency.

Organization Name

Are you a certified MHANYS CarePath Coach?

Yes No Currently certified MHANYS CarePathTM Coaches are eligible for dual-certification and a reduced-hour Mental Health Community Partners Certification Training. More information will be provided upon approval of your MHCP Partner Application.

Do you provide MHANYS CarePath services?

Yes No

Demographic Information

This information will solely be used for research and reporting purposes, and will not be shared with your employer or any other entities.

Gender

Do you identify as part of the LGBTQ+ community?

Race

Ethnicity

Fluent Language(s)

English

Spanish

Other (please specify)

Year of Birth

Do you identify as a peer (i.e. person with lived behavioral health experiences)?

Do you support a family member with a behavioral health condition?

Do you identify as a person with a disability (physical and/or mental health condition?

Are you a veteran?

Yes No

Short Answer Responses

What has called you personally to help and support others?

If certified as a Mental Health Community Partner, how will you utilize the program in your agency and/or community?

Accessibility Information

Accommodations for individuals with a disability may be arranged on a case-by-case basis. If you require accommodations, please describe the nature of your disability, and reasonable accommodations that you may need to successfully participate in this training. Supporting documentation (e.g. letter from a healthcare provider, supervisor, or HR representative of current employer) will be required.