SUPERVISING PSYCHIATRIST MANUAL
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First Name: Last Name:
Practice or
Organization:
City:
State:

Zip Code:


Email:   
What is your Profession?
Physician
Nurse Practitioner/Physician Assistant
Mental Health Specialist
Administrator
Quality Improvement Leader
Nurse/Medical Assistant
Care Manager
Educator
Researcher
Other
What is your primary work setting?
Medicine/Healthcare
Mental/Behavioral Health
Education
Health Insurance
Other
What will downloaded material be used for?
Own professional/clinical use
Teaching of clinicians/care managers
Reference only
Other
If materials will be used in training/educational activities:
Who will be the audience?
Medical professional/staff
Mental/behavioral health professional/staff
Students in a college/university setting
Other
What size is the audience?
1 to 20 participants
20 to 50 participants
50 to 100 participants
100 to 300 participants
300 to 500 participants
500+ participants