Form 1 NIMH Computational Psychiatry Workshop Registration Form

NIMH Computational Psychiatry Workshop Registration

OMB # 0925-0740

Expiration Date: 05/2019

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NIMH Computational Psychiatry Workshop

(EVENT DATE)

(EVENT LOCATION)

Sponsored by the National Institute of Mental Health (NIMH)

Registration

To register for the workshop on (EVENT DATE), please provide the information requested below. You will receive a confirmation e-mail from (ORGANIZING COMMITTEE EMAIL) following your submission of this completed online form.

There is no registration fee and no on-site registration.

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Contact Information

• denotes required information

First Name •:

Last Name •:

Title •:

Organization •:

Degree•:

Career level •:

Gender:

Street Address •:

Suite I Apt I Box City •:

State/Province/Region •:

Zip/Postal Code •:

Country •:

Phone (include country code if you are an international participant) •:

Email address •:

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Meeting Preparation

Please provide a one paragraph description of your expertise and background:

Please provide up to 5 relevant citations:

Please provide a photo:

Please provide 1-2 bullet points to address the following questions to help the organizers refine the agenda:

• What are the key open questions in the field of computational psychiatry?

• What are the next steps to take in the field of computational psychiatry?

• What are the challenges of the field of computational psychiatry?

Are you interested in presenting a poster/model?

Are you willing to chair a session on (TOPIC)?

Are you interested in giving a talk?

Will you require lodging on the night of (DATE)?

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Visa Assistance

For international attendees requiring visa assistance, please contact (ORGANIZING COMMITTEE EMAIL) as soon as possible.

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Accommodations

Individuals with disabilities who may require sign language and/or reasonable accommodation to participate in this workshop should contact (ORGANIZING COMMITTEE EMAIL). Requests should be made at least 10 days in advance of the workshop.

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Lunch

Due to the closure of the (MEETING LOCATION) cafeteria, a box lunch will be available for (COST) from (VENDORS). Options are below. Please make a selection for each day.

Day 1
□	(Option 1)
□	(Option 2)
□	(Option 3)
□	(Option 4)

Day 2
□	(Option 1)
□	(Option 2)
□	(Option 3)
□	(Option 4)