Bridges to Mental Health Registration Form

The Bridges to Mental Health program trains primary care, specialty physicians, advanced practice providers, nurses, and mental health workers to:

improve their diagnostic and therapeutic skills;
strengthen their confidence to expand their care; and
heighten their awareness of common psychiatric disorders.

This workforce training–believed to be the first of its kind nationally–helps mitigate the access crisis by initiating early mental health treatment in areas where patients and the public already come for care.

Step 1 of 3

33%

Event Details

The seminar takes place over two days through a series of engaging and interactive presentations. Attendees earn 13 CME. The sessions and CME are free thanks to Clarkson Institute and generous ongoing support from the Hawks Foundation. Upon registering, you will receive more information. CME claim instructions will be sent a few days after the conclusion of the training. Please note the timeframes for the two days: 9 AM-4:30 PM.

Which session are you registering for?(Required)

Nebraska City (January 25-26): Lied Lodge at Arbor Day Farm

South Sioux City (January 28-29): Marriott South Sioux City Riverfront

Omaha (May 3-4): Location TBA

Valentine (May 6-7): Location TBA

Hastings (September 13-14): Location TBA

Omaha (September 16-17): Kiewit Luminarium (Pediatric focus)

Your Contact Information

Name(Required)

First Last

Email(Required)

All communications around this program will be sent to this email Confirm Email

Phone

Affiliation/Organization(Required)

Primary Practice Location(Required)

Street Address Address Line 2 City State ZIP Code

Dietary Restrictions

Please indicate below if applicable.

Gluten free

Vegetarian, dairy ok

Vegetarian, no dairy

Other/additional dietary restrictions and/or allergies

If you checked the "Other" box above, please specify and we will do our best to accommodate.

Feedback

Where did you hear about this training event?(Required)

Thank you for being as specific as possible

Pre-Event Survey

Thank you for your interest in attending “Bridges to Mental Health.” Program leaders are interested in understanding more about those participating in the program for future planning efforts and to better understand the impact the program is having on access to care. Please respond to the questions below, which should take ~5 minutes.

How old are you?(Required)

<35 years old

35-44 years old

45-54 years old

55-65 years old

>65 years old

What is your gender identity?(Required)

Female

Male

Non-binary/Third gender

Prefer not to say

What is your role?(Required)

Healthcare Professional

First responder

Student

Teacher

Other

What is your practice specialty?(Required)

Family Medicine

General Internal Medicine

General Pediatrics

Internal Medicine Subspecialty (please list your subspecialty in the next field)

OB/GYN, Women’s Health

Pediatrics Subspecialty (please list your subspecialty in the next field)

Psychiatry or Psychology

Other (please list in the next field)

If applicable, please list your Subspecialty and/or "Other" practice specialty.

How many years have you practiced in this specialty?(Required)

<5 years

5-10 years

11-20 years

>20 years

What is your professional degree?(Required)

Please check all that apply.

MBA

MD/DO

PhD

Other (please list in the next field)

If you selected "Other" professional degree(s), please list here.

Enter your degree/credential abbreviation EXACTLY as it should appear on official documents (eg. badge, transcript). If not applicable, please so indicate.(Required)

Please provide your NPI number.

What is your practice location zip code?(Required)

How many years have you practice at this location?(Required)

<5 years

5-10 years

11-20 years

>20 years

What health professional school did you attend?(Required)

Timely access to clinical experts for the mental/behavioral health care needs of my patients is…(Required)

Always adequate

Usually adequate

Often inadequate

Completely inadequate

At present, I am comfortable assessing and managing the following conditions:

Please select for each condition below.

Depression(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Anxiety(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Bipolar disorder(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

OCD(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Post traumatic stress disorder (PTSD)(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Substance use disorder (SUD)(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

New onset psychosis(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Suicidal ideation(Required)

Strongly agree

Somewhat agree

Somewhat disagree

Strongly disagree

Consent

I agree to participate in an evaluation of the impact of this program on access to mental/behavioral health care for Nebraskans. I understand that all data will be kept secure and HIPAA compliant, with no individual patient level data examined at any time. Additionally, my data will remain anonymized in all data analysis and reporting.(Required)

Yes