Course Enrolment Form HiddenName First Last HiddenEmail address 1. Which area best describes your location of work?* a) Alice Springs b) Darwin c) Katherine d) Nhulunbuy e) Palmerston f) Tennant Creek g) Other location in the Northern Territory (please describe below) h) Outside of the Northern Territory Your location in the Northern Territory: 2. Which type of organisation best describes your workplace?* a) Alcohol and Drug Specialist Community/Out-patient Service b) Hospital c) Other Healthcare Service d) Other Community Service e) Other (please describe below) Other: 3. Is your workplace a:* a) Aboriginal Community Controlled Health Organisation (ACCHO) b) Government Department c) Not-for-profit service d) Private Business e) Other (please describe) Other: 4. Which best describes your current role?* a) Aboriginal Health Worker b) Allied Health Practitioner (occupational therapist, physiotherapist etc) c) Case Manager d) Counsellor (psychologist, social worker, therapist, counsellor etc) e) Medical Practitioner (doctor, nurse) f) Other (please describe) Other: 5. How long have you worked with people experiencing difficulties with their alcohol and/or other drug use?* a) Less than 12 months b) 1 – 5 years c) 6 – 10 years d) 10+ years 6. What is your gender?* a) Male b) Female c) Intersex d) Other e) Prefer not to say 7. What is your age group?* a) 19 years and under b) 20 – 29 years c) 30 – 39 years d) 40 – 49 years e) 50 -59 years f) 60 – 69 years g) 70 + EmailThis field is for validation purposes and should be left unchanged.
