Certificate Course in Common Mental Disorders (CCCMD)

Participant Enrolment Form

Instructions:

Upload softcopy of Photo (in JPG format only), MCI/NMC Certificate , MBBS Degree (in JPG, JPEG, PNG and PDF format)
Snapshot/screenshot of payment details to be uploaded (in JPG, JPEG, PNG and PDF format)
For all file upload, maximum size would be 250kb

SECTION I: PERSONAL DETAILS

Participant Name *

Gender *

Date of Birth *

Mobile *

Whatsapp Number *

Email *

Photo *

Alternate Email

Current Affiliation *

If Others, Please Specify

Medical College/Teaching Affilliation

Yes

No

If Yes

Location of Practice *

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SECTION II: PLACE OF WORK

Place of Work *

Street *

Landmark *

City *

District *

State *

Pincode *

SECTION III: RESIDENTIAL ADDRESS SAME AS ABOVE:

Residence Address *

Street *

Landmark *

City *

District *

State *

Pincode *

Preferred Mailing Address *

SECTION IV: MCI/NMC REGISTRATION DETAILS

MCI/NMC Registration No. *

Registration Certificate *

Registration Date *

State *

SECTION V: QUALIFICATION

MBBS *

College/Institution/Board/University

Year of Passing

Attach Proof

MD/MS

College/Institution/Board/University

Department

Year of Passing

Attach Proof

DNB

College/Institution/Board/University

Department

Year of Passing

Attach Proof

DM/PhD

College/Institution/Board/University

Department

Year of Passing

Attach Proof

Diploma

College/Institution/Board/University

Department

Year of Passing

Attach Proof

Others

College/Institution/Board/University

Department

Year of Passing

Attach Proof

MBBS Outside India *

SECTION VI: PROFESSIONAL/CLINICAL EXPERIENCE

Total Professional/Clinical Experience: *

Year

Month

Total Years of experience in dealing with mental disorders and management *

Year

Month

Average no of patients treated per month

Out of all patients treated by you, how many suffer from mental disorders

SECTION VII: FACULTY/CENTER PREFERENCE

Preferred State *

Preferred Center *

Preferred Faculty *

* Confirmation subject to availability of seats

SECTION VIII: TRANSACTION/PAYMENT DETAILS

Mode of Payment (NEFT, UPI etc) *

Transaction Reference No. *

Payment/Transaction Receipt *

Date of Payment/Transaction *

Bank Name *

Branch Name *

SECTION IX: Feedback

Please indicate the motivation and benefits you foresee in undergoing this course: *

I hereby declare that the above mentioned information, which I have provided, is true to the best of my knowledge. I shall participate in the contact sessions organised once in a month on weekend and will devote self-reading time for the entire five modules and participate in the assessments, organised by the offering institution. I also give my consent for publishing my feedback/testimonial which I will provide to the Secretariat in any report or publication produced by PHFI. I understand that CCCMD is not a degree but a certificate course with the objective of training doctors in the prevention and management of common mental disorders and successful participants are not entitled to mention/call themselves as psychiatrists anywhere after completion of this course. I also understand that this certificate course is not a recognised Medical Qualification, under section 11 (1) of the Indian Medical Council Act 1956 and the Institution offering this course is neither a medical college or a university nor offering the course in accordance with the provisions of the Indian Medical Act/University Grants Commission Act.