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ECHO Nursing: Strengthening Connections Registration Form

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We welcome you to join the ECHO Nursing Strengthening Connections, Building a Community of Practice to Support Well-being and Counter Stress Program . This program is designed for all Registered Nurses in Ontario to share and learn about ways to build resilience and wellness through didactic lectures and case-based discussions.

First Name:

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Last Name:

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Email Address:

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Phone Number:

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Extension (if applicable):

Name of Organization:

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Organization Address:

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Organization City:

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Organization Postal Code:

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Which LHIN is your organization a part of?

NOTE: If you are unsure, please input your organization's postal code on this website: http://www.lhins.on.ca/

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Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

North East

North Simcoe Muskoka

North West

South East

South West

Toronto Central (U of T)

Waterloo Wellington

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What is your primary profession? Select all that apply.

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Registered Nurse

Nurse Practitioner

Registered Practical Nurse

Other

Please specify:

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Are there any topics you would like to see covered in ECHO Nursing: Strengthening Connections?

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Have you participated in any other ECHO(s) in the past?

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Yes

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If yes, which ECHO(s)?

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ECHO Ontario Addiction Medicine and Psychosocial Interventions

ECHO Ontario Adult Intellectual & Developmental Disabilities

ECHO Ontario Integrated Mental and Physical Health

ECHO Ontario Mental Health

ECHO Ontario Obsessive Compulsive Disorder

ECHO Ontario Psychotherapy (CBT, DBT or Developmental Trauma and Resilience)

ECHO Ontario Trans and Gender Diverse Healthcare

ECHO Ontario First Nations, Inuit and Métis Wellness

ECHO Coping with COVID

ECHO Critical Care & Emergency Nurse Wellbeing

Other

Attached below is the ECHO Nursing: Strengthening Connections Statement of Collaboration that outlines certain conditions which must be understood and agreed to in order to participate in this program.

Please review the Statement of Collaboration.

Attachment:ECHO Nursing Strengthening Connections - Statement of Collaboration.pdf

Carefully review and check to indicate your agreement to the following statements.

ECHO didactics, Q&As, discussions and case presentations do not create or establish a provider-patient/client relationship between any hub clinician and a patient/provider/resident whose case is presented.

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I agree

I do not agree

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Personal identifying information about patients/clients/providers/residents is not to be shared during ECHO sessions. If this inadvertently occurs, I will follow my own organization's policies and procedures to address the privacy breach.

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I agree

I do not agree

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Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to care providers, residents, and/or my patients/clients.

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I agree

I do not agree

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The ECHO team records sessions for educational purposes and occasionally takes photos for promotion.

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I agree to this statement, and give ECHO Nursing: Strengthening Connections permission to share photo(s) of me externally in presentations, reports and promotional materials. I understand my name, profession, and/or organization will not be included with the photo.

I agree to this statement, but I do not wish to have my photo shared externally. I understand any image of me will be blurred in photos used in externally facing presentations, reports, and promotional materials.

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I have read and agree to the terms of the Statement of Collaboration with preferences as indicated above.

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I agree

I do not agree

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Initial Here

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Add signature

Please provide date:

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D-M-Y

Your submission will be reviewed by our operations team and your participation will be confirmed as soon as possible.

After you have received confirmation of your enrollment in the program we will contact you by email and provide details about next steps.

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.