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Center for Professional Health

2015 Program for Distressed Physicians Enrollment Form
 
Sponsored by Vanderbilt University School of Medicine and the Center for Professional Health.
Vanderbilt University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical Education for physicians.
 
Target Audience Physicians whose workplace behavior has become problematic. 
 

You may pay in full online with your Credit Card for the three day course and three one day follow-up sessions (includes continental breakfast, lunches, and CME fees- $4525). If paid by check the cost is 4500. A non-refundable deposit of $300 is required to confirm a space in the course. The balance of the fee ($4200) may be paid on the first day of the course. Please make checks payable to VUMC. 

Course enrollment is limited to 6 participants. A phone interview with William H. Swiggart, M.S., L.P.C. is required prior to registration. Please call 615.936.0678 to schedule. Please complete the registration form after your interview. Your registration confirmation will be sent by mail.
 
 
NAME:
SUFFIX: (Eg.MD, PhD, etc.)
NAME TAG:
SPECIALTY:  
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE:
FAX:  
E-MAIL:
REFERRED BY:
 
EMERGENCY CONTACT: Please provide name and phone # of the individual whoe should be contacted in case of emergency.
Name:
Phone:
 
Program for Distressed Physicians 2015 COURSE DATES: (Please select)
A phone interview with William H. Swiggart, M.S., L.P.C. is required prior to registration.
 
January 28-30 (Plus 3 one-day f/u sessions over 6 months – dates TBA) 
April 8-10 (Plus 3 one-day f/u sessions over 6 months – dates TBA)
July 15-17(Plus 3 one-day f/u sessions over 6 months – dates TBA)
October 21-23 (Plus 3 one-day f/u sessions over 6 months – dates TBA)
 
A continental breakfast and box lunch will be provided daily. If you have special dietary requirements, please let us know. 
 
Comments:
 

PAYMENT OPTIONS: Credit card payments are accepted online only. If you prefer to pay by CHECK you may pay on SITE or by MAIL.

ONLINE VIA CREDIT CARD (Pay in Full)Please return to CPH mainpage and click Online Payment tab after you have submitted this form

CHECK/MONEY ORDER/CASH( Payable to VUMC)

 

The daily course schedule (subject to change), goals, and objectives are available on our website.
 
Designation of Credit Vanderbilt University School of Medicine designates this educational activity for a maximum of 48.25 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
 
Faculty Disclosure It is the policy of Vanderbilt University School of Medicine to require disclosure of financial relationships from individuals in a position to control the content of a CME activity; to identify and resolve conflicts of interest related to those relationships; and to make disclosure information available to the audience prior to the CME activity.  Presenters are required to disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentations.
 
All course directors, planners, and speakers indicated no financial relationships to disclose.
 
Cancellation Policy:  If you must cancel your registration, your $300 deposit is non-refundable.  Your registration may be transferred to another course date.  In the event of cancellation or rescheduling of this CME activity due to unforeseen circumstances, Vanderbilt University will refund the registration fee in full.  Vanderbilt University is not responsible for non-transferable, non-refundable airline tickets or hotel accommodations purchased in connection with attendance at this CME activity.

 

Course Faculty

William Swiggart, M.S., L.P.C./MHSP
Assistant in Medicine, Department of Medicine
Co-Director, Center for Professional Health
Vanderbilt University Medical Center
 
Tobi Fishel, Ph.D.
Assistant Professor of Psychiatry
Director of Psychological Services
Vanderbilt Center for Integrative Health
Ronald E. Neufeld, B.S.W., L.A.D.A.C.
Program Director
Vanderbilt Comprehensive Assessment Program for Professionals (VCAP)
 
Linda L.M. Worley, M.D., FAPM
Adjunct Clinical Professor of Medicine
Vanderbilt University Medical Center
Professor of Psychiatry and Obstetrics & Gynecology
University of Arkansas for Medical Sciences
 
 Vanderbilt Center for Professional Health (CPH)
1107 Oxford House · Nashville TN 37232-4300

 

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