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Project ECHO: Sign In Form
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Your Information
Name
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First Name
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Last Name
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Work Email
Personal Email
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Place of Work
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Location Type
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Inpatient
Outpatient/Ambulatory
Nursing Home/Long Term Care
State Agency
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Other:
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Credentials
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MD
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Psychologist
MFT/CPC
LADC
Social Worker (SW, MSW, LCSW, etc.)
PhD
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MA (Medical Assistant)
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Credentials (Other)
Do you practice in a primary care setting?
*
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Are you interested in reviewing a patient case during an ECHO session?
*
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No
I don't know what this is
Do you practice in Nevada?
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Please select the counties in which you practice (check all that apply):
Carson City
Churchill
Clark
Douglas
Elko
Esmeralda
Humboldt
Lander
Lincoln
Lyon
Mineral
Nye
Pershing
Storey
Washoe
White Pine
How did you hear about Project ECHO Nevada?
Email from Project ECHO Nevada
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Project ECHO Nevada website
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Flyer/brochure
Conference/presentation
Social media
Word of mouth
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