iECHO Registration Form

WNYCCCED

Project ECHO® Eating Disorders (ECHO® EDO)

Registration for TeleECHO

If you wish to receive email notifications of and participate in the WNYCCED Project ECHO® Eating Disorders sessions for the clinical management of patients with eating disorders and their families, please complete the registration information below and click ‘Done’ at the bottom of the page.

Yes, I wish to register for the WNYCCCED Project ECHO® EDO Clinics coordinated by the University of Rochester School of Nursing and available through a ZOOM platform.

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* 1. Organization Name

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* 2. Name

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* 3. Credentials (MD, NP, PHP, etc.)

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* 4. Specialty

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* 5. Title / Role
e.g. Social Worker, Physician, Psychotherapist, etc

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* 6. Address

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* 7. City / State / Zip Code

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* 8. County

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* 9. Phone

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* 10. Login Phone
The phone number that you would use when logging into the echo sessions

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* 11. Email

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* 12. Your Website URL (If available)

Project ECHO® Eating Disorders Clinics are eligible for continuing education credits through the Center for Experiential Learning at the University of Rochester Medical Center. Attendance is required to qualify for CME / CEU for a session. Instructions to receive CME /CEU will be communicated each session. Currently, CME / CEU is provided at no cost to Project ECHO® Eating Disorders TeleECHO participants.

To learn more about our TeleECHO Clinics for Eating Disorders you may contact us:

Email: wnyccced@urmc.rochester.edu Phone: 585-275-2936

WNYCCCED is funded in part by NYS Department of Health Division of Chronic Disease Prevention Project ECHO URSON Registration 09.29.3016

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100% of survey complete.

Question Title

* 1. Organization Name

Question Title

* 2. Name

Question Title

* 3. Credentials (MD, NP, PHP, etc.)

Question Title

* 4. Specialty

Question Title

* 5. Title / Role e.g. Social Worker, Physician, Psychotherapist, etc

Question Title

* 6. Address

Question Title

* 7. City / State / Zip Code

Question Title

* 8. County

Question Title

* 9. Phone

Question Title

* 10. Login PhoneThe phone number that you would use when logging into the echo sessions

Question Title

* 11. Email

Question Title

* 12. Your Website URL (If available)

* 5. Title / Role
e.g. Social Worker, Physician, Psychotherapist, etc

* 10. Login Phone
The phone number that you would use when logging into the echo sessions