Thank you for your interest in being a mentee in the Collaborative Mentorship Networks (CMN) for Chronic Pain and Addiction.

The Alberta College of Family Physicians (ACFP) respects your privacy.  The information collected on this form will be used for administration and evaluation of the CMN.  Personal information will only be shared with staff at the ACFP for administrative purposes, and with your mentor in order to initiate your mentoring relationship.

Only aggregated, de-identified information will be submitted to the Primary Health Care Opioid Response Initiative for grant reporting purposes.

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* 1. Do you agree to allow the ACFP to use the information provided for the purposes outlined above?

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* 2. Please provide your full name

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* 3. Please provide your contact information

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* 4. Are you a member of a Primary Care Network (PCN)?

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* 5. Which best describes you?

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* 6. With respect to your MAIN patient care/practice setting, describe the population primarily served by you in your practice (please select only one option).

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* 7. What best describes your work setting(s)?  Please select ALL that apply.

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* 8. Please describe what you are hoping to achieve through mentoring.

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* 9. How did you hear about the Collaborative Mentorship Networks for Chronic Pain and Addiction?

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