Prior Approval Request Form - Infant & Early Childhood Mental Health Training

(For best results, please fill out this form using the Google Chrome Browser.)

Important Notes:
• Submission of this form does not guarantee approval.
• You will be notified of the decision once the request has been reviewed.
• Please submit this form at least one week prior to the program start date.
• Approval will be provided through email from the Department of Social Work

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Current Employer *

Training Details

Name of Program or Course *

Name of Institution or Provider *

Program Location - City and State *

Program Start Date *

Program End Date *

Program Duration - Number of Days and/or Hours *

Program Type * In-Person Virtual Hybrid

Describe program, objectives, key takeaways *

Additional Comments or Notes

Provide additional information that may be relevant to your request