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?
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)
Why are you interested in Prevention Practitioner training? (Please choose one answer)
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)
Do you intend on practicing as a Prevention Practitioner? (Please choose one answer)
Please select the choice with which you best identify (Please choose one answer)
What is your preferred official language for professional communications? (Please select all that apply)
Who will be providing payment for your registration fees? (Please choose one answer)
Please provide the contact details of the person who should be contacted regarding payment of your registration fees.
Dates of training session for which you want to register
How did you hear about the BETTER Prevention Practitioner Training Institute? (Please choose all the answers that apply)
