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Mental Health ECHO Enrolment Form
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1.
First name
(Required.)
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2.
Last name
(Required.)
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3.
Email address
(Required.)
4.
Mobile number
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5.
What is your profession?
(Required.)
GP Specialist
Medical Specialist (please specify in Other)
Mental Health Medical Officer
IMG
Junior Doctor/Intern
Nurse
Paramedic / Ambulance Officer
Pharmacist
Psychologist
Social Worker
Allied Health Professional (please specify in 'Other')
Other (please specify)
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6.
Primary workplace name
(Required.)
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7.
Primary workplace suburb/town
(Required.)
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8.
Is your work location classified as:
(Required.)
Metropolitan SA
Regional SA
Rural SA
Other (please specify)
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9.
Do you have a clinical case you would like to present for discussion?
(Required.)
Yes
No
Unsure
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10.
What would you like to gain from joining the Mental Health ECHO?
(Required.)
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11.
For each of the curriculum topics listed below, please share your learning needs, questions or requests for specific focus areas:
(Required.)
ATSI mental health
Perinatal mental health: anxiety and depression
Older persons mental health: psychosis vs delirium
Youth eating disorders
Psychosis: psychotropics and cardiometabolic effects
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12.
How did you hear about the Mental Health ECHO Program?
(Required.)
SAPMEA
RACGP or ACRRM
Social media
Colleague
SALHN
Office of the Chief Psychiatrist
Other (please specify)
13.
If you are an RACGP member please provide your RACGP ID.
Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each meeting attended.
GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)
14.
If you are an ACRRM member please provide us with your ACRRM membership number.
Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each meeting attended.
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15.
Would you like to subscribe to our fortnightly newsletter?
(Required.)
Yes, please subscribe me
I am already subscribed
No, I am not interested
