Motivational Interviewing Introduction and Application Course: Pre Registration form

Please fill out this pre-registration form to be considered for the motivational interviewing (MI) introduction and application course. Pre-registration is the first phase of course registration process. If you do not submit your pre-registration form, you will not be able to register for the course.

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* 1. Please indicate your name, email address and work title/position

Name:

Email address:

Work title/Position

Discipline

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* 2. Briefly describe the patient population with whom you work.

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* 3. Briefly describe your practice setting and your main responsibilities with patients

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* 4. Indicate your interest in this course (you may select more than one response)

As an elective for the Opioid dependence treatment certificate program

As an elective for the Concurrent disorders certificate program

Seeking information for your staff/organization

I want to implement motivational interviewing in my practice

General interest in the practice of motivational interviewing

Other (please specify)

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* 1. Please indicate your name, email address and work title/position

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* 2. Briefly describe the patient population with whom you work.

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* 3. Briefly describe your practice setting and your main responsibilities with patients

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* 4. Indicate your interest in this course (you may select more than one response)

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* 5. CAMH staff members, please provide your CAMH email address