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Title *
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Surname *
First Name *
Email Address *
Contact Phone Number *
Primary Practice Address (please include your street address ) *
State
Profession *
Required
Please select the area of expertise you are will present on (the closest) *
Required
What are your presentation topic titles? (this will be used on network invitations) *
Please identify the three main topic titles which you would like to present.
Biography *
Network meeting promotional items include an outline of the topic to be covered and the presenter's bio. Please provide a short (150 words max) bio about yourself and your clinical experience. It is important to note that this information will only be shared with MHPN members.
Please indicate your availability to present at network meetings. *
All MHPN network meeting are held during the working week (Mon- Fri), mainly outside office hours. I am able to present:
Required
Is there any other information you would like us to know?
Privacy *
MHPN is currently building a guest speaker register resource so that our networks can engage the most appropriate speaker to cover the topics in which they are interested. Initially this information will only be used internally, however in the future MHPN anticipates having the ability to make it available to network coordinators on our website. Please indicate what details (if any) you would be comfortable displaying on our website.
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