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Black Dog Institute

Clinician Registration as MAP Referrer

 
 
I wish to register to refer patients to undertake MAP assessments.

ONE FORM SHOULD BE SUBMITTED FOR EACH LOCATION AND EACH PROVIDER NUMBER
 
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Security
The security of your personal information is important to us. We use a third party web-based service operated by QuestionPro in the USA for conducting surveys. The data remains controlled by us. QuestionPro follows industry standards to protect personal information and uses secure socket layer (SSL) technology. More information on QuestionPro and their Privacy Policy is available on their website at www.questionpro.com. However, no method of transmission over the internet, or method of electronic storage is 100% secure. Therefore, while we strive to use commercially acceptable means to protect your personal information, we cannot guarantee its absolute security. By using this service you understand that we use the QuestionPro service and consent to the transfer of relevant data to the USA based system. We also encourage you to take responsibility for the security of your own computer system.

Information provided to the Black Dog Institute will not be sold or traded to any other person under any circumstances.
If you have any questions please email blackdog@blackdog.org.au
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