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ECHO Canada Adult Intellectual and Developmental Disabilities: Mental Health in the Time of COVID-19 Application Form

Thank you for your interest in ECHO Canada Adult Intellectual and Developmental Disabilities: Mental Health in the Time of COVID-19. Please complete the following application form to be considered for the upcoming cycle.

Note: Applicants will be placed on a waiting list if program becomes full.

I am a

Service provider

Family member/friend of an adult with an intellectual or developmental disbility

Self advocate

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Please note that this application form is for the service provider course ONLY.

If you are a family member/friend of an adult with an intellectual or developmental disability please use this link to apply: https://edc.camhx.ca/redcap/surveys/?s=9L7AXHJ9JP

If you are a self advocate, please contact irfan.jiwa@camh.ca to apply.

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:

Province:

* must provide value

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

Nunavut

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Name of Organization (if possible, please avoid acronyms):

* must provide value

Organization Address:

* must provide value

Organization City:

* must provide value

Organization Postal Code:

* must provide value

What type of setting(s) do you practice in?

* must provide value

Urban

Rural

Both urban and rural

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What is your primary profession? Select which best applies.

* must provide value

Addictions Counsellor

Audiologist

Behaviour Analyst/Behaviour Therapist

Case Worker/Case Manager/Care Coordinator

Community Health Worker

Developmental Service Worker/Direct Support Professional

MD (Family Physician)

MD (Specialist)

Nurse Practitioner

Occupational Therapist

Pharmacist

Physician Assistant

Physiotherapist

Psychologist

Psychotherapist

Registered Nurse

Registered Practical Nurse

Social Worker

Speech Language Pathologist

Student

Other

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Please specify area of specialty:

* must provide value

Please specify area of study:

* must provide value

Please specify profession:

* must provide value

Please indicate your primary practice setting:

* must provide value

Aboriginal Health Access Centre

Academic Hospital

Community Addictions Agency

Community Health Centre

Community Mental Health Agency

Community Mental Health and Addictions Agency

Community Support Services Agency

Developmental Services Community Agency

Nurse Practitioner-led Clinic

Private Practice / Solo Practitioner

Team Primary Care Practice

Residency

University/College Health Care Centre

Other

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Please specify:

* must provide value

How many years have you been practicing?

* must provide value

Have you participated in ECHO at CAMH before?

* must provide value

Yes

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Please note that ECHO sessions are virtual and interactive. It is strongly recommended that you use either a laptop, desktop computer, tablet, or smartphone (with working speakers and microphone) to connect to the weekly sessions so that we are able to interact with you.

It is particularly helpful to see you virtually during ECHO in order to build an effective community of practice. Do you anticipate you will be able to turn your camera on in ECHO sessions?

* must provide value

Yes No

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If no, please describe rationale:

* must provide value

Please note that ECHO Canada Adult Intellectual and Developmental Disabilities: Mental Health in the Time of COVID-19 will run every Thursday from 1:30 - 3:00 p.m. EST from January 14, 2021 to February 18, 2021.

Your participation in this ECHO will include the following:
• Carefully reviewing and signing a Statement of Collaboration agreement (see below);
• Attending a 45-minute online orientation session or reviewing an orientation document prior to the first session if you have never participated in one of our ECHO programs;
• Attending as many of the weekly sessions as possible;
• Completing a pre-survey, weekly surveys, and post-survey
• Delivering a short anonymized case presentation about a client in your practice during a session

NOTE: Visit our website at https://camh.echoontario.ca/programs-aidd/ for more information about program curriculum.

Do you currently work with adults with intellectual and/or developmental disabilities?

* must provide value

Yes

Not at this time, but I would like to in the future

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Why are you interested in participating in ECHO Canada Adult Intellectual and Developmental Disabilities?

* must provide value

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What are you interested in learning?

* must provide value

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How would you rank your familiarity with the Intellectual and Developmental Disabilities population? Select one.

* must provide value

Not at all familiar

Slightly familiar

Somewhat familiar

Moderately familiar

Extremely familiar

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How would you rank your familiarity with mental health? Select one.

* must provide value

Not at all familiar

Slightly familiar

Somewhat familiar

Moderately familiar

Extremely familiar

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Is there anything else you would like to share with us regarding your application for this ECHO?

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An important part of the ECHO model is to discuss real, complex patient cases, collectively ask pertinent questions, and develop recommendations for care. All personal information must be de-identified. Prior to the launch of the ECHO cycle we will work with you on an agreed-upon date for a case presentation, and will help you to prepare and submit this anonymized client case through a case form. We hope that you and your client will see this exercise as a helpful opportunity to share and receive feedback from the community of practice. Please confirm the following:

Are you currently working in direct practice with clients?

* must provide value

Yes

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Do you have a case you would like to discuss during one of the ECHO sessions?

* must provide value

Yes, I have someone in mind

No, I cannot think of anyone right now, but I will do so prior to ECHO

No, I do not think I can present a case

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If so, please provide a brief rationale:

* must provide value

Attached below is the ECHO Statement of Collaboration that outlines certain conditions which must be understood and agreed to in order to participate in any of our ECHO programs.

Please review the Statement of Collaboration.

Attachment:ECHO Ontario Mental Health_SoC - National AIDD 2020_Final.pdf

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

I will participate in at least 60% of sessions.

* must provide value

I agree

Not sure due to schedule uncertainties, but I will attend as many sessions as possible

I cannot attend 60% of sessions

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Please specify why:

* must provide value

ECHO case presentations do not create or establish a provider-patient client relationship between any Hub clinician and a patient whose case is presented.

* must provide value

I agree

I've read the SOC, but have questions. Please contact me. I understand that the ECHO team at CAMH will require my agreement to this item from the SoC prior to my attendance in the session.

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Personal identifying information about patients/clients 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.

* must provide value

I agree

I've read the SOC, but have questions. Please contact me. I understand that the ECHO team at CAMH will require my agreement to this item from the SoC prior to my attendance in the session.

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

* must provide value

I agree

I've read the SOC, but have questions. Please contact me. I understand that the ECHO team at CAMH will require my agreement to this item from the SoC prior to my attendance in the session.

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

* must provide value

I agree to this statement, and give the ECHO team at CAMH 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.

I've read the SOC, but have questions. Please contact me.

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My participation data will be shared with the funding agencies, ECHO Ontario Superhub, and ECHO Institute as outlined in the Statement of Collaboration.

* must provide value

I agree

I agree to have my data shared with the funding agencies and ECHO Ontario Superhub, but want to opt out of sharing with ECHO Institute.

I've read the SOC, but have questions. Please contact me.

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

* must provide value

I agree

I've read the SoC, but have questions and understand I will be contacted to discuss this prior to being enrolled in the program

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Initial Here

* must provide value

Add signature

Please provide date:

* must provide value

D-M-Y

We have scheduled a videoconference orientation session on January 12th, 2021 from 1:30 - 2:30 am EST. Information about case discussion, how to access the session, and the Community of Practice website will be provided during this orientation.

Please select one of the below options:

* must provide value

I can attend the orientation on January 12th, 2021 from 1:30 - 2:30 pm EST

I cannot attend the orientation and I will need to be sent an orientation PDF package

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This application 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 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.