<p> VISN 5 MIRECC CAP Expert Advisor Application</p><p>Thank you for your interest in the VISN 5 MIRECC Clinician Advisory Panel (CAP). When we convene the CAP we select CAP members based on their interests and knowledge. Please provide the following information so that we can best utilize your expertise. Completed CAP applications can be returned to Samantha Hack at [email protected] </p><p>Name:</p><p>Job title:</p><p>VA clinic assignment:</p><p>Highest professional degree: (ex: PhD in Psychology, Masters of Social Work)</p><p>Expertise Keywords</p><p>Populations: (ex: OIF/OEF/OND; elderly; women)</p><p>Interventions: (ex: motivational interviewing; prolonged exposure; psychosocial rehabilitation)</p><p>Diagnoses: (ex: PTSD; dual diagnoses; co-occurring physical and mental health disorders)</p><p>10 N. Greene Street • Baltimore, Maryland 21201 • 410-637-1850 • Fax 410-637-1880</p>