SOCIAL WORK NETWORK IN PALLIATIVE AND END-OF-LIFE CARE LISTSERV
DEPARTMENT OF PAIN MEDICINE AND PALLIATIVE CARE
BETH ISRAEL MEDICAL CENTER, NEW YORK
NAME: ___________________________________________________________________
PREFERRED MAILING ADDRESS: _______________________________________________
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INSTITUTIONAL AFFILIATION: _________________________________________________
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PHONE: Work: ______________________ Home: ____________________
EMAIL: _____________________________ Fax: ______________________
PLEASE INDICATE YOUR DISCIPLINE AND PRIMARY AREA OF PRACTICE.
DISCIPLINE: ___________________________________________________
NUMBER OF YEARS IN POST MSW PRACTICE: ____________________
AREA OF PRACTICE:
CHRONIC PAIN:___________ GERIATRICS:____________
HIV:___________ HOSPICE:____________
NEPHROLOGY:___________ ONCOLOGY:___________
PALLIATIVE CARE - END OF LIFE: ___________
PALLIATIVE CARE - ALONG CONTINUUM OF ILLNESS:____________
PEDIATRICS: ____________ PRIVATE PRACTICE:_________
RESEARCH: _____________ OTHER (SPECIFY): __________________________
INPATIENT: _____________ OUTPATIENT: ___________
AREAS OF SPECIALIZATION: (i.e., Bereavement, pain, hypnosis, family, etc.)
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DO YOU LECTURE IN THESE AREAS? YES_______________NO___________________
DO YOU WRITE / PUBLISH? YES_________________NO__________________________
HOW DID YOU HEAR ABOUT THIS LISTSERV? NEWSLETTER: _______
COLLEAGUE / FRIEND: _______ INTERNET POSTING: ___________
OTHER (SPECIFY): ____________________
PLEASE LIST THE PROFESSIONAL ORGANIZATIONS IN WHICH YOU ARE A
MEMBER (i.e., AOSW, ASPBOA, NASW, NHPCO, APS, CANCER PAIN INITIATIVES, etc.)
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DATE: _________________________
Tel: 212-844-1467 Fax: 212-844-1503
Email: taltilio@chpnet.org