Advanced Dementia ECHO Enrolment Form

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* 1. First name

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* 2. Last name

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* 3. Email address

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* 4. Mobile number

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* 5. What is your profession?

GP Specialist

Non- GP Specialist (please also select other and specify)

Nurse

IMG

Junior Doctor

Pharmacist

Allied Health Professional (please also select other and specify)

Other (please specify)

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* 6. Workplace name

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* 7. Workplace suburb

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* 8. Is your work location classified as:

Metropolitan SA

Regional SA

Remote SA

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* 9. Would your work environment be described as

Solo practice

Team of practitioners from the same clinical discipline

Team of practitioners of different clinical disciplines

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* 10. Do you have a patient case you would like to discuss at the network?

Yes

Unsure

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* 11. What would you like to gain from joining the Dementia ECHO?

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* 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

Dementia and memory assessment in primary care and aged care.

Dementia prevention and addressing modifiable risks.

Critical care conversations with family and people living with advanced dementia.

Advanced care planning for people living with dementia.

Care planning in complex patient presentations and situations.

Management of neuropsychiatric symptoms of dementia.

End of life care in advanced dementia.

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* 13. How did you hear about the Dementia ECHO Program?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / Wellbeing SA

GP Integration Unit

Direct email invitation

Social media

Word of mouth

Other (please specify)

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* 14. If you are a RACGP member and would like to claim 4 CPD hours for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.

Note: RACGP members who attend at least 4 sessions and participate in both the planning and review meeting will be eligible to receive 4 CPD hours for a Reviewing Performance activity under the Peer-Group Learning model. RACGP members who do attend fewer than 4 sessions, will still receive an attendance certificate to self-claim CPD hours.

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* 15. If you are an ACRRM member and would like to claim CPD hours for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number.

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* 16. Would you like to subscribe to our fortnightly newsletter?

Yes

No, I am already subscribed

Ni, I am not interested