Request for AAAP Technical Assistance 

ACGME Accreditation Addiction Psychiatry Fellowship

Please print the following form, complete it and mail it to AAAP, 1010 Vermont Ave, Suite 710, Washington, DC 20005 or fax it to (202) 393-4419. 

Date ___________________________________________

Department Chair _________________________________

Institution ________________________________________

Academic Affiliation ________________________________

Person to Contact _________________________________

Title ____________________________________________

Phone __________________________________________

Fax ____________________________________________

E-mail __________________________________________

Name of Residency Program for which ACGME addiction psychiatry certification is sought _______________________

_______________________________________________

Participating Institutions (Hospitals, etc.) ________________

_______________________________________________

_______________________________________________

Number of Physician Faculty Members _________________

Number with CAQ in Addiction Psychiatry _______________

Number of Residents per Year 

PGY 1 ________  PGY 2 ________  PGY 3 ________

Do you have affiliation agreements with:

Inpatient Facilities? If yes, which ones?

Partial Hospitalization and Day Treatment Centers? If yes, which ones?

Ambulatory Care Services? If yes, which ones?

Additional Comments: