Heidelberg Balint Network EOI

1. About you

By filling out this survey you are indicating an interest in joining a multidisciplinary lunchtime Balint group based in Heidelberg, facilitated by Dr Sally Manuell (GP) and Marcel Saxone (pharmacist and psychotherapist).

The sessions will run from 12.30 to 2pm once a month on a Friday, with lunch provided, at the Mount Street Medical Centre general practice, 80 Mount Street Heidelberg, which is situated within a very short distance from the Heidelberg train station and the Austin Hospital.

Please only fill out this expression of interest if you are willing and able to commit to attending these sessions regularly.

Question Title

* 1. Name:

Question Title

* 2. What is your profession?

General Practitioner

Psychologist

Social Worker

Psychiatrist

Occupational Therapist

Mental Health Nurse

Paediatrician

Other

Please specify

Question Title

* 3. Would you be willing to subsidise the cost of paying a Balint supervisor?

Yes

Question Title

* 4. If you answered yes to the previous question please indicate the amount that you would be willing to contribute to each meeting.

$10

$20

Question Title

* 5. Practice contact Details:

Practice Address:

Phone:

Email Address:

FAX Number:

Thank you for filling out this expression of interest. If there is enough interest in establishing a lunchtime Heidelberg Balint group then we will plan an initial meeting sometime in early 2012 and you will receive an invitation. If you do not receive an invitation then that is an indication that the interest did not warrant the establishment of a group at this stage.