Perinatal Depression Learning Community - Participant Recruitment

Thank you for your interest and taking the time to complete this application to the Perinatal Depression Learning Community!

The AAP will host a learning community (cohort) consisting of ten one-hour sessions from May through September.

Each session will focus on one of the following topics: perinatal depression screening tools, engaging caregivers in discussions and counseling on protective factors for primary care intervention, identifying epidemiology of perinatal depression, describing risk factors that increase perinatal depression, providing culturally sensitive, humble, and effective in office counseling for perinatal depression and making referrals/linkages a norm in the medical community. Each cohort will accommodate up to 15 participants.

We look forward to learning more about you and your interest in this opportunity. Thank you!

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* 1. Your name

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* 2. Your preferred email address

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* 3. Your profession/role?

Pediatrician

Nurse Practitioner

Physician's Assistant

Mental Health Specialist (e.g. Social Worker, Counselor)

Allied Health (e.g., Nutritionist, Therapist, Health Educator)

Ob/Gynecologist

Other Physician

Other Nurse

Other (please specify)

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* 4. Agency/Center/ Practice Name

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* 5. Agency/Center/Practice Zipcode

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* 6. Is someone else from your agency/center/practice applying for this Learning Community along with you?

Yes

Don't Know

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* 7. Which of these is your primary work environment?

Private Practice

FQHC or Look-a-like

Hospital-based clinic

Other (please specify)

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* 8. What percentage of your patients at your practice site are covered by the following insurance sources and systems? (Note: your total should add up to 100%.)

Private insurance, either fee-for-service or managed care

Public insurance (Medicaid, SCHIP, or other)

Uninsured, self-pay

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* 9. Did you obtain information about payer mix from your practice’s billing (or other) system or is it an approximation?

Billing (or other) System

Approximation

If necessary, please explain briefly:

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* 10. Briefly highlight the 1-3 key ways in which your agency/center/practice addresses perinatal depression.

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* 11. What level of support do you have from your administration/leadership and colleagues for engaging in and implementing the learnings from this opportunity.

A lot of support

Some support

Little support

No support

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* 12. What would you like to learn, or what experience would you like to gain from this Learning Community?

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* 13. A requirement to participating in this Learning Community would be to complete the online Pedialink Course on Perinatal Depression. Do you have access to Pedialink?

Yes

If no please contact Xochitl Salvador at xsalvador@aap.org.

Thank you for taking time to complete this application, we will inform you if you have been selected for this opportunity.