CCPS Members Needs Assessment Survey

Please answer each of the following questions regarding your personal educational needs.

Are you a member of CCPS? : *

yes

If so, which chapter?:

In what city do you live?: *

In what city do you practice?: *

Are you employed faculty of a university?: *

Yes

If so, which university?:

Are you volunteer clinical faculty of a university?: *

Yes

If so, which university?:

How many years have you been practicing psychiatry (including residency) ?:

Specialty:

What percentage of your working hours is spent among the following tasks?

Patient care: medication management : %

Patient care: psychotherapy : %

Administration : %

Research : %

Supervision/teaching medical students or residents : %

Supervision/teaching of other healthcare professionals: %

Answer the following Areas of Need on a scale of 1 to 5: 1 if it is already well developed (further need not required), up to 5 if it is absolutely needed.

Psychosomatic medicine and somatoform disorders:

Treating Children, Adolescents and Families:

Please provide any specific information you may require regarding the above elements.:

Are there speakers you have heard and enjoyed that we should consider inviting to present our Annual Meeting in the future? :

What have we forgotten? We welcome your comments and suggestions:

May we contact you with more questions (e.g. future surveys, focus groups, etc.)?

Name:

Email:

Address:

Phone:

	1	2	3	4	5
Information(Assessment, diagnosis, etc.)
Skills (Psychotherapy, medication management, etc.)

	1	2	3	4	5
Information (Assessment, diagnosis, etc.)
Skills (Psychotherapy, medication management, etc.)