Thank you for expressing your interest in completing the 'Caring for patients who use alcohol and other drugs: a skills-based training program for general practice' workshop and follow-up-webinar.
Please complete this form by 5pm AEDT on Friday, 11 August 2023
If you have any queries, please contact education@nwmphn.org.au

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* 1. What is your full name?

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* 2. What is your occupation?

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* 3. Which general practice do you work for?

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* 4. What is the address of your general practice?

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* 5. What is your preferred email address? Please note that this can't be a shared email address.

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* 6. What is your preferred contact number?

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* 7. I confirm that I am a GP or practice nurse located in the NWMPHN region

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* 8. I confirm that I will attend both the face-to-face workshop and the follow-up webinar

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* 9. Provide 100-200 words explaining why you would like to participate in this training

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* 10. Provide 100-200 words describing how your patients will benefit from you undertaking this training

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* 11. Please provide any additional information to support your application

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