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Mental Health Committee - Join
Please complete this brief form to join the AAPCA1 Mental Health Committee.
*
1.
Full Name
(Required.)
*
2.
Email Address
(Required.)
3.
Practice Setting:
Private (solo or group)
FQHC
Employed/Foundation Model (non-Kaiser)
Kaiser
Academic Setting
Other (please specify):
4.
Where are you in your career?
Medical Student
Resident
Fellow
In practice less than or equal to 10 years
In practice greater than 10 years
Emeritus/Retired
5.
Specialist vs Primary Care (please select one)
Primary Care
Specialist (list specialty)
6.
What do you hope to get out of this committee?
7.
What ideas do you have for this committee?
(e.g. goals, activities, etc.)
Thank you for joining! We will be in touch with you soon.
