Elsternwick Lunchtime Balint Network EOI

1. About you

By filling out this survey you are indicating an interest in joining a multidisciplinary lunchtime Balint group based in Elsternwick, facilitated by Dr Bill Betts (Psychiatrist) and Hilary Ash (Social Worker).

The sessions will run every 6 weeks during lunchtime, day of the week TBC.

Please only fill out this expression of interest if you are willing and able to commit to attending these sessions regularly.

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* 1. Name:

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* 2. What is your profession?

General Practitioner

Psychologist

Social Worker

Psychiatrist

Occupational Therapist

Mental Health Nurse

Paediatrician

Other

Please specify

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* 3. Which of the following days of the week would you be available for meetings? (You may nominate more than one day)

Monday

Thursday

Friday

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* 4. Would you be willing to subsidise the cost of paying a Balint supervisor?

Yes

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* 5. If you answered yes to the previous question please indicate the amount that you would be willing to contribute to each meeting.

$10

$20

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* 6. Practice contact Details:

Practice Address:

Phone:

Email Address:

FAX Number:

Thank you for filling out this expression of interest. If there is enough interest in establishing a lunchtime Elsternwick Balint group then we will plan an initial meeting sometime in early 2012 and you will receive an invitation. If you do not receive an invitation then that is an indication that the interest did not warrant the establishment of a group at this stage.