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opJfIvnubL8qWPtFUa6i7j9k59K6nWsqN3MUjbkcVvbnLxGP9hWCP6ydQUmVLTgNDhJxaAzpRaPfMDhby33PDBtLrje6pCPTLtT9piR5Vd2U3anb3YDL3c

ECHO IMPH Pop-Up: Long COVID - Registration Form (March 19, 2024)

The ECHO Ontario Integrated Mental and Physical Health Pop-Up night session on the topic 'Long COVID' will take place on Tuesday, March 19, 2024 from 6:00 PM to 7:15 PM EST.

If you are interested in attending, please complete the short application below. We will be in touch to confirm your participation.

First Name:

* must provide value

Last Name:

* must provide value

Email Address:

* must provide value

Phone Number:

* must provide value

Extension (if applicable):

Alternative Phone Number:

Name of Organization:

* must provide value

Organization Address:

* must provide value

Organization City:

* must provide value

Organization Postal Code:

* must provide value

What is your primary profession? Select all that apply.

* must provide value

Addictions Counsellor

Case Worker/Case Manager/Care Coordinator

Community Health Worker

Developmental Service Worker/Direct Support Professional

MD (Family Physician)

MD (Specialist)

Nurse Practitioner

Occupational Therapist

Other

Pharmacist

Physician Assistant

Physiotherapist

Psychologist

Psychotherapist

Registered Nurse

Registered Practical Nurse

Social Worker

Speech Language Pathologist

Student

Please specify area of study:

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Please specify:

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Please indicate your primary practice setting:

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Private Practice / Solo Practitioner

Family Health Team

Family Health Organization

Family Health Group

Community Health Centre

Community Health Agency

Nurse Practitioner-led Clinic

University/College Health Care Centre

Residency

Academic Hospital

Other

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Please specify:

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Which LHIN are you a part of?

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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

Waterloo Wellington

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Have you participated in an ECHO Ontario Mental Health program before?

* must provide value

Yes

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Please specify (select all that apply):

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Addictions Medicine & Psychosocial Interventions

Adult Intellectual & Developmental Disabilities

Critical Care & Emergency Nurse Well-Being

First Nations, Inuit, and Métis Wellness

General Mental Health

Integrated Mental and Physical Health

Obsessive Compulsive Disorder

Psychotherapy

Trans & Gender Diverse Healthcare

Do you have any specific questions for the Q&A?

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Do you have a client case to bring forward to the group? If so, please provide a brief description:

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Attached below is the ECHO ONMH Confidentiality & Data Use Agreement that outlines certain conditions which must be understood and agreed to in order to participate in an ECHO pop-up session.

Please review the ECHO Confidentiality & Data Use Agreement attached.

Attachment:ECHO IMPH - Statement of Collaboration - Long COVID Pop Up Session - Mar. 19, 2024.pdf

My participation data will be shared with the Ministry of Health, ECHO Ontario Superhub, and the Project ECHO Institute at the University of New Mexico as outlined in the Confidentiality & Data Use Agreement

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I agree

I agree to have my data shared with the Ministry of Health, ECHO Ontario Superhub, and the Project ECHO Institute at the University of New Mexico

I've read the Confidentiality & Data Use Agreement, but have questions. Please contact me to discuss.

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I have read and agree to the terms of the Confidentiality & Data Use Agreement.

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I agree Please contact me

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Initial Here

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Add signature

Please provide date:

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D-M-Y

Please select 'Submit' in order to submit your application.

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

You have selected an option that triggers this survey to end right now.

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.