Treating Chronic Pain Post-Test Section I. Demographics Question Title * 1. What is your name? OK Question Title * 2. What is your email address? OK Question Title * 3. What is your profession / discipline? Behavioral Health – Social Work Behavioral Health – Psychology Behavioral Health – Addiction Counseling Dentistry Medicine Nursing Paraprofessional Public Health Physician Assistant Student – Graduate Studies Student – Paraprofessional Student – Undergraduate Studies Other (please specify) OK Question Title * 4. What is your highest degree? Health Sciences - PA Health Sciences - MD Health Sciences - DO Nursing - RN Nursing - BSN Nursing - MSN Psychology - BA Psychology - MA (Counseling Psychology) Psychology - Psy. D. Psychology - Ph. D. Social Work - BSW Social Work - MSW Social Work - DSW Social Work - Ph. D. Other (please specify) OK Question Title * 5. Please fill out your professional license information: Type: State: Number: OK Question Title * 6. Are you employed by any of the following IBHC Community Partners? Please check all that apply. Baystate Medical Center Partial Hospitalization Program Baystate Medical Center Family Advocacy Center Brien Center Caring Health Center CHD Outpatient/DBT Program Clinical & Support Options, Inc. Family Health Center of Worcester Friends of the Homeless Mercy Life Mass Center for Integrated Primary Care New England Hospice Providence Behavioral Health Hospital Swift River West Central & Family Counseling Gandara Center Edward M Kennedy Community Health Center OK Question Title * 7. If not employed by any of the IBHC partners listed in Question #6, please list the name of your employer. OK Question Title * 8. What is the address of your agency / employer? (Please include zip code) OK Question Title * 9. Do we have your permission to let your employer know that you participated in this learning module? Yes No OK Question Title * 10. Please select the populations served by your agency, choose all that apply: Adolescents Children Chronically ill College students Homeless individuals Individuals with HIV / AIDS Individuals with mental illness or substance use disorders Lesbian/Gay/Bisexual/Transgender Low income persons / families Migrant workers Pregnant women and infants Refugee adults People with disabilities Undocumented immigrants Unemployed Returning war veterans (Iraq or Afghanistan) Veterans Transitional age youth (16-25 years) Uninsured / underinsured persons / families Tribal populations Victims of abuse or trauma None of the above Other (please specify) OK NEXT
