Anxiety and Depression ECHO® Registration Form

Please complete the following information to participate in the Project ECHO® Program: Managing Anxiety & Depression in the Pediatric Practice. Our Behavioral Health Coordinator will contact you as soon as possible to confirm your registration and provide additional details. We encourage your participation in all 6 sessions for the complete learning experience. Thank you and we look forward to providing you with this complimentary educational opportunity.

(Please complete this form for each participant)

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* 1. Cohort Preference

Cohort 1: CLOSED

Cohort 2: (August 4, August 11, September 8, September 22, October 13, October 27)

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* 2. Name (First, Last)

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* 3. Email

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* 4. Title/Credential:

Primary Care Pediatrician

Pediatric Subspecialist

Other (please specify)

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* 5. Years in practice ?

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* 6. Practice or Facility Name:

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* 7. Practice or Facility Address:

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 8. Type of Practice/Facility:

Pediatric

FQHC

Other (please specify)

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* 9. Number of Physicians in Practice:

0-3

3-5

Do you anticipate anyone else participating from your office? YES or NO

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* 10. By participating in Project ECHO, I am giving consent to be recorded and to have those recordings shared with other medical professionals

I agree

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* 11. Active participation is required and participants are expected to present at minimum one case during the course of the series

I understand

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* 12. Would you like to receive information about signing-up for Georgia Mental Health Access in Pediatrics (GMAP) program?

Georgia Mental Health Access in Pediatrics (GMAP) is a free program which helps pediatric providers take better care of children and adolescents with behavioral health concerns through provider educational programs (such as this ECHO), improved access to behavioral health experts via a teleconsultation advice line, and access to a referral network of behavioral health resources.

Yes