TIS Department of NYSPI- ONLINE REQUEST

Email Request Form:

Please note this: once you submit the form, your supervisor will receive an automatic email asking for a confirmation. Please type in your supervisor's full name and email address correctly. Your request will NOT be processed until your supervisor approves your request.

Upon supervisor's approval, the case will be logged into the CASESENTRY Help Desk System and your supervisor will receive a case number. To check on the status of your request, please contact your supervisor.

If you are a member of the department of Child Psychiatry or DRAT, DO NOT fill out this form. Please email support@childpsych.columbia.edu

Items with * are required.

Requested by: (If requested by a third person)
Requestor's email address:
Funding Source:
First Name: *
Last Name: *
Title: *
Department: * If Other, please specify:	Other:
Location: *
Preferred Email Password:
What email client will the user be using: *	Other:
Do you need the GroupWise software?	Yes No
Work Phone:
Work Fax:
Employed By: *	RFMH Columbia NY State
Expiration Date:(mm/dd/yy) *
Supervisor's Full Name: *
Supervisor's Email: *