GMAP: Managing Anxiety and Depression: A Deeper Dive ECHO® Registration Form

Thank you for your interest in our Project ECHO® Program: Managing Anxiety & Depression: A Deeper Dive. Utilizing the ECHO model "all teach, all learn" approach. Each ECHO session includes a brief presentation, followed by a case presentation submitted by participants for discussion, problem-solving, guidance and recommended follow-up. All attendees are strongly encouraged to actively participate during each virtual ECHO session.

Please complete the following information to participate.

Thank you and we look forward to providing you with this complimentary educational opportunity.

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* 1. Cohort Preference (all sessions will be 12:30-1:30PM)

Cohort 1 on the following Tuesdays: March 21, April 11, April 25, May 9, May 23, June 6

Cohort 2 on the following Fridays: March 24, April 14, May 5, May 19, June 16, July 28

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* 2. Name (First, Last)

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* 3. Enter Your Date of Birth (mm/dd/yy)
This information is only to create a unique identifier

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* 4. Email

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* 5. Title/Credential:

Primary Care Pediatrician

Pediatric Subspecialist

Nurse Practitioner

Nurse

Other (please specify)

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* 6. Years in practice ?

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* 7. Practice or Facility Name:

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* 8. Practice or Facility Address:

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 9. Type of Practice/Facility:

Pediatric

FQHC

Other (please specify)

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* 10. Number of Physicians in Practice:

0-3

4-6

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

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* 11. 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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* 12. 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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* 13. Would you like to register for the 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. By registering with GMAP, you agree to providing your feedback to the Evaluation Team, (i.e. brief surveys, etc.) as required by HRSA. Your feedback helps us improve the program.

Yes

GMAP: Managing Anxiety and Depression: A Deeper Dive ECHO® Registration Form

Question Title

* 1. Cohort Preference (all sessions will be 12:30-1:30PM)

Question Title

* 2. Name (First, Last)

Question Title

* 3. Enter Your Date of Birth (mm/dd/yy)This information is only to create a unique identifier

Question Title

* 4. Email

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* 5. Title/Credential:

Question Title

* 6. Years in practice ?

Question Title

* 7. Practice or Facility Name:

Question Title

* 8. Practice or Facility Address:

Question Title

* 9. Type of Practice/Facility:

Question Title

* 10. Number of Physicians in Practice:

Question Title

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

Question Title

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

Question Title

* 3. Enter Your Date of Birth (mm/dd/yy)
This information is only to create a unique identifier