Mental Health ECHO Enrolment Form Series 2

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* 1. First name

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* 2. Last name

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* 3. Email address

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* 4. Mobile number

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* 5. What is your profession?

GP Specialist

Medical Specialist (please specify in Other)

Mental Health Medical Officer

IMG

Junior Doctor/Intern

Nurse

Paramedic / Ambulance Officer

Pharmacist

Psychologist

Social Worker

Allied Health Professional (please specify in 'Other')

Other (please specify)

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* 6. Primary workplace name

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* 7. Primary workplace suburb/town

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* 8. Is your work location classified as:

Metropolitan SA

Regional SA

Rural SA

Other (please specify)

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* 9. Do you have a clinical case you would like to present for discussion?

Yes

Unsure

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* 10. What would you like to gain from joining the Mental Health ECHO?

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* 11. For each of the curriculum topics listed below, please share your learning needs, questions or requests for specific focus areas:

ADHD in adults

ADHD in children

Addiction and substance abuse in trauma and anxiety

Tobacco cessation in mental health population

Physical Health - The things you don’t think about

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* 12. How did you hear about the Mental Health ECHO Program?

SAPMEA

RACGP or ACRRM

Social media

Colleague

SALHN

Office of the Chief Psychiatrist

Other (please specify)

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* 13. If you are an RACGP member please provide your RACGP ID.

Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each meeting attended.

GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)

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* 14. If you are an ACRRM member please provide us with your ACRRM membership number.

Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each meeting attended.

Mental Health ECHO Enrolment Form Series 2

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address

Question Title

* 4. Mobile number

Question Title

* 5. What is your profession?

Question Title

* 6. Primary workplace name

Question Title

* 7. Primary workplace suburb/town

Question Title

* 8. Is your work location classified as:

Question Title

* 9. Do you have a clinical case you would like to present for discussion?

Question Title

* 10. What would you like to gain from joining the Mental Health ECHO?

Question Title

* 11. For each of the curriculum topics listed below, please share your learning needs, questions or requests for specific focus areas:

Question Title

* 12. How did you hear about the Mental Health ECHO Program?

Question Title

* 13. If you are an RACGP member please provide your RACGP ID. Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each meeting attended.GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)

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* 14. If you are an ACRRM member please provide us with your ACRRM membership number.Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each meeting attended.

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* 15. Would you like to subscribe to our fortnightly newsletter?

* 14. If you are an ACRRM member please provide us with your ACRRM membership number.

Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each meeting attended.