Diabetes and Mental Health Network EOI

1. About you

By filling out this survey you are indicating an interest in joining a Mental Health Professionals Network group that has a focus on Diabetes and Mental Health.

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* 1. Name:

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* 2. What is your profession?

General Practitioner

Psychologist

Social Worker

Psychiatrist

Occupational Therapist

Mental Health Nurse

Paediatrician

Diabetes Educator

Dietician

Other

Please specify

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* 3. Practice contact Details:

Practice Address:

Practice Phone:

Mobile:

Email Address:

FAX Number:

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* 4. Please check the box next to the topics that are of interest to you.

Psychosocial and mental health impacts of living with and managing diabetes

Depression and diabetes

Anxiety and diabetes

Major psychiatric illness and diabetes (eg schizophrenia, bipolar disorder, cognitive impairment)

Drug dependence and diabetes

Other (please specify)

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* 5. In addition to your involvement as a network member, would you also be interested in being part of a multi-disciplinary steering committee for this network? This would involve contributing to planning for the network, and having input into the network's focus and meeting agendas.

Yes

Thank you for filling out this expression of interest. If there is enough interest in establishing a Diabetes and Mental Health network then we will plan an initial meeting for early 2012 and you will receive an invitation. If you do not receive an invitation in the new year then that is an indication that the interest did not warrant the establishment of a network at this stage.