Starting a program from scratch is one of the most rewarding and exciting career opportunities institutional Graduate Medical Education leadership and/or a program director will encounter. Being able to meaningfully address psychiatric workforce shortages through residency education opportunities is incredibly fulfilling. It is also a time of significant challenge, and personal and programmatic cultural growth. It requires initial residency developers to withstand crises, infuse a leadership culture that sets the stage for excellence, create a foundational funding structure that can withstand the rigors of shifting financial sands, and maintain an enthusiastic and flexible training environment that meets the needs of an emerging healthcare and educational system. Attention to detail is paramount in the initial stages of residency development, as successful program accreditation depends on focus and strong organizational skills. The authors of this chapter have all been involved in the start-up of brand-new programs, either as program directors or as a member of the first residency class. This chapter reviews key elements of starting a new program, including funding, mission and vision, sponsorship, faculty recruitment and retention, accreditation, program director characteristics and role, resident recruitment, faculty development, curriculum development, and scholarship.