First Name:
* must provide value
Last Name:
* must provide value
Email:
* must provide value
Confirm Email:
* must provide value
The emails do not match. Please check and re-enter in the fields above.
Clinic/Facility Name (please tell us about the one where you spend the most time):
* must provide value
Clinic/Facility Address:
* must provide value
Clinic/Facility City:
* must provide value
Clinic/Facility Zip Code:
* must provide value
Please list all counties where you practice:
Approximately how many patients are in your practice:
Number of clinicians in your practice:
Now, please tell us a little about yourself.
Which of the following choices best describes your race? Select all that apply.
White
Black/ African American
American Indian/Alaska Native
Asian
Hawaiian/ Pacific Islander
Other
What other race do you consider yourself?
Do you consider yourself Hispanic or Latino?
Yes
No
Do you currently describe yourself as male, female, transgender, nonbinary, or other?
Male
Female
Transgender
Non binary
Other
Prefer not to answer
How many years have you been in practice?
What is your clinical degree (check all that apply):
* must provide value
MD
DO
PhD/PsyD
PharmD
Nurse Practitioner
Physician Assistant
MSW
MA/MS
BA/BS
Student
Other, please specify
Not applicable
Please specify your degree:
What is your primary function:
PCP
Psychiatrist/Psychologist
Other mental healthcare provider
Provider of social work services
Rehabilitation medicine physician
Vocational rehabilitation counselor
Neurologist
Other, please specify
Please specify your primary function:
Considering all of your clinical sites, what percentage of your patients have these comorbid conditions:
(Please provide your best estimate of percentage, from 0 - 100. If none, please enter zero. We understand you may not have an exact number. An estimate is fine, and will better help us understand your needs.)
Indicate % by entering a number between 0 and 100.
Substance Use Disorder (SUD):
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Are there other conditions that frequently affect your patients with a history of TBI that are not listed?
Yes
No
Indicate % by entering a number between 0 and 100.
Please specify what other conditions you are treating (if applicable):
Please list the 'Other' conditions you are treating
Considering all of your clinical sites, what percentage of your patients have the following social determinants of health:
(Please provide your best estimate of percentage, from 0 - 100. If none, please enter zero. We understand you may not have an exact number. An estimate is fine, and will better help us understand your needs.)
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Indicate % by entering a number between 0 and 100.
Lack of health care insurance:
Indicate % by entering a number between 0 and 100.
Are there other social determinants of health that frequently effect your patients that are not listed?
Yes
No
Indicate % by entering a number between 0 and 100.
How confident do you feel with the diagnosis and management of the following:
Working in my practice has allowed me to experience joy in my work:
Very untrue
Untrue
Neither true nor untrue
True
Very true
Do you feel isolated from or connected to the general medical community?
Very isolated
Somewhat isolated
Neither isolated nor connected
Somewhat connected
Very connected
Do you feel satisfied with the available TBI/etc. resources in your community?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
How satisfied are you with the consultative resources (or expert consultation) for TBI in your community?
Very dissatisfied
Somewhat dissatisfied
Neither dissatisfied nor satisfied
Somewhat satisfied
Very satisfied
Which of the following TBI resources are you aware of?
BIAWA (Brain Injury Alliance of Washington)
Other
Please specify resources.
Please rate each on a scale of 1 (not important) to 5 (very important)
Please share your other reason(s) for participating:
How did you learn about TBI BH ECHO? Please check all that apply:
Website (UW TBI BH website)
Website (UW Dept of Psychiatry & Behavioral Sciences)
Website (other, please specify)
Colleague(s)
Media
Professional conference
Professional publication
Other, please specify
Please specify how you learned about TBI BH ECHO:
What topics would you like to see covered in this series?
