Please complete this brief form to join the AAPCA1 Mental Health Committee. 

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* 1. Full Name

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* 2. Email Address

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* 3. Practice Setting:

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* 4. Where are you in your career?

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* 5. Specialist vs Primary Care (please select one)

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* 6. What do you hope to get out of this committee?

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* 7. What ideas do you have for this committee? 
(e.g. goals, activities, etc.)

Thank you for joining! We will be in touch with you soon.
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