Prevention Practitioner Training Registration Form













    Mailing address (where you want your training materials mailed prior to the session):

















    How many years have you been in practice (current health care profession)



    Do you currently work in primary care?


    YesNo

    Where do you currently practice? (Please provide information in the space provided)






    With respect to your main practice setting, describe the population primarily served by you in your practice. (Select all that apply)


    Geographically isolated/remoteIndigenousRuralSmall townUnderservedUrban/suburban

    Why are you interested in Prevention Practitioner training? (Please choose one answer)


    Personal/professional developmentI’m interested in bringing the BETTER program to my organizationMy primary care organization is interested in having a Prevention PractitionerOther



    Is your main practice setting receiving implementation support from the BETTER Institute? Implementation support means that members of your practice are currently working with the BETTER Institute team to help integrate the program into your workflow. (Please choose one answer)


    YesNoI don't know

    Do you intend on practicing as a Prevention Practitioner? (Please choose one answer)


    YesNoNot sure

    Please select the choice with which you best identify (Please choose one answer)


    MaleFemaleSelf-identifyI prefer not to answer



    What is your preferred official language for professional communications? (Please select all that apply)


    EnglishFrench

    How did you hear about the BETTER Prevention Practitioner Training Institute? (Please choose all the answers that apply)


    BETTER advertisement (i.e. in a newsletter)BETTER Program websiteColleagueEmployerMedia (i.e. local paper, commercial, radio, etc.)Presentation/conferenceOther