REGISTRATION & PRE-PROGRAM SURVEY

REGISTRATION Registration for the course is required before you can log on and commence the course. I have read the acknowledgements and disclaimers above. - Yes No When you have completed and submitted this program registration screen you will be taken to a secure online payment screen. Following completion of the this screen and the payment screen you will be emailed your login details within 3 working days. Please complete and submit the details below. Are you a: - Credentialed Mental Health Nurse but not a member of the ACMHN Nurse, midwife, or student who is not a member of the ACMHN Title: First Name: Surname: Contact Phone: Contact Mobile: Most Reliable Email: Member Number: Credential Number (if applicable): The following information will be de-identified. Q1a. Gender: - Male Female Q1b. Age Range: - 20-29 30-39 40-49 50-59 60-65 +65 Q2. Have you ever received training in women's reproductive health, particularly relating to counselling in pregnancy? - Yes No Q3. Are you a: - Mental health nurse with specialist qualifications A general nurse working in mental health A general nurse in another are A midwife practising in a midwifery area Other Other (please specify): Q4. Your place of work: - General practice surgery Community mental health service Private practice Other Other (please specify): Q5. Why do you want to counsel women who have pregnancy related concerns? Q6. Are you receiving clinical supervision? - Yes No If yes, how often do you have clinical supervision sessions? - Occasionally (only when I need it) Monthly More than monthly Other (please specify) Other (please specify): Q7. Will you receive clinical supervision in relation to your role as a pregnancy counsellor? - Yes No