Are you an Ontario-based healthcare provider?
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Yes
No
Please note that the programs in this application form are intended for Ontario-based healthcare providers only. Applicants who are not based in Ontario and/or who are not healthcare providers (or current students working toward a healthcare provider designation) will not be considered for program enrollment.
To learn about other ECHO programs offered in Canada, please visit https://canada.echoontario.ca/.
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):
Alternative Phone Number:
What is your primary profession? Select which best applies.
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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 (GP Psychotherapist)
MD (Specialist)
Nurse Practitioner
Occupational Therapist
Pharmacist
Physician Assistant
Physiotherapist
Psychologist
Psychotherapist
Registered Nurse
Registered Practical Nurse
Social Worker
Speech Language Pathologist
Student
Other
Please specify area of study:
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Please specify:
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Name of Organization (if possible, please avoid acronyms):
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Organization Address:
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Organization City:
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Organization Postal Code:
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Name of Educational Institution (if possible, please avoid acronyms):
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Educational Institution Address:
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Educational Institution City:
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Educational Institution Postal Code:
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Which Ontario Health Region is your organization/institution a part of?
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North East Region
North West Region
East Region
Central Region
Toronto Region
West Region
What type of setting(s) do you practice in?
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Urban
Rural
Both urban and rural
N/A - currently do not practice
Please indicate your primary practice setting: Note: Please only select "Community Health Centre" if your organization follows the CHC model. For more information click here.
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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
Family Health Group
Family Health Organization
Family Health Team
Nurse Practitioner-led Clinic
Private Practice / Solo Practitioner
Residency
University/College Health Care Centre
Other
N/A - currently do not practice
Please specify:
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What is the size of your organization or practice?
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How many years have you been practicing?
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0 to 1 2 to 5 6 to 10 11 to 15 16 to 19 20+
Have you participated in an ECHO program in the past?
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Yes
No
Which ECHO program(s)?
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Please note that ECHO Coping with Covid and ECHO Nursing: Strengthening Connections follow a slightly different format than our other programs, in that there is limited case-based learning. All of our Winter 2025 programs will feature case-based learning components (most often a case presentation from a participant, followed by a discussion about the case).
If other, please specify:
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Will others from your team participate in this ECHO?
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Yes No
NOTE: Please make sure that any member of your team who will participate completes this application. We require an application from each participant.
How did you hear about ECHO Ontario Programs?
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Communications from professional association (e.g. newsletter, bulletin)
Email from ECHO Ontario Mental Health
Word of mouth (e.g. colleague)
Conference
Other
Please specify which association you belong to:
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Please specify:
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We are interested in supporting providers who may be working with underserved populations. Please describe the populations that you work with.
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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 we are able to interact with you.
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Yes No
If no, please describe rationale:
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Please note that your participation in this ECHO will include the following:
https://camh.echoontario.ca/our-programs/ Which ECHO Ontario program(s) are you applying for? [Reminder: These programs run concurrently. Please check the dates and times indicated below to confirm your availability.]
Please note, for "PROGRAM AT CAPACITY ," all available spots have been filled. A
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If you are applying to multiple programs, please rank your top choices: NOTE: We will attempt to place you in your highest ranked ECHO. Enrollment is not guaranteed.
Choice 1:
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ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 3: Concurrent Disorders & Complexity ECHO Ontario Psychotherapy DBT ECHO Ontario Integrated Mental and Physical Health ECHO Ontario Adult Intellectual and Developmental Disabilities
Choice 2:
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ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 3: Concurrent Disorders & Complexity ECHO Ontario Psychotherapy DBT ECHO Ontario Integrated Mental and Physical Health ECHO Ontario Adult Intellectual and Developmental Disabilities
Choice 3 (if applicable):
ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 3: Concurrent Disorders & Complexity ECHO Ontario Psychotherapy DBT ECHO Ontario Integrated Mental and Physical Health ECHO Ontario Adult Intellectual and Developmental Disabilities
If the above programs reach capacity, would you be interested in joining the following ongoing program if there is room?
ECHO Ontario General Mental Health (Tuesdays, 2:00 - 4:00pm, October 1, 2024 - March 25, 2025)
Yes No
Why are you interested in participating in ECHO Ontario Mental Health Programming? (select all that apply)
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Please specify:
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ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 3: Concurrent Disorders and Complexity Note: This program has been developed with physicians and nurses in mind, as well as other healthcare professionals from interprofessional teams.
Module 3: Concurrent Disorders and Complexity will review assessment and interventions for individuals with co-occurring mental health and substance use disorders, with a focus on complex client populations (e.g., people with severe and persistent mental illness).
Did you attend Module 1 (Spring 2024) or Module 2 (Fall 2024) of ECHO Ontario Addiction Medicine and Psychosocial Interventions?
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Yes, I attended Module 1
Yes, I attended Module 2
Yes, I attended Modules 1 and 2
No, I did not attend Modules 1 or 2
Why are you interested in participating in ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 3: Concurrent Disorders and Complexity?
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What are you interested in learning?
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ECHO Ontario Psychotherapy Module 2: Dialectical Behavioural Therapy (DBT) Note: ECHO Ontario Psychotherapy is a three module program which aims to share knowledge and skills for Dialectical Behaviour Therapy (DBT), Cognitive Behaviour Therapy (CBT), and Developmental Trauma & Resilience (DTR). This module is designed for allied health care providers who would like to integrate DBT principles and strategies into their current practice.
Are you a member of one of the following colleges?
How often do you work with clients living with borderline personality disorder (BPD), emotional dysregulation, impulsivity, suicidality, and/or self-harm?
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Never
Rarely (i.e. every few months)
Occasionally (i.e. every few weeks)
Somewhat often (i.e. weekly)
Very often (i.e. daily or almost daily)
Have you had any prior training or education in Dialectical Behavioural Therapy (DBT)?
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Yes
No
Please explain:
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How often do you use Dialectical Behavioural Therapy (DBT) techniques in your practice?
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Never
Rarely (i.e. every few months)
Occasionally (i.e. every few weeks)
Somewhat often (i.e. weekly)
Very often (i.e. daily or almost daily)
What are you hoping to gain from the ECHO Psychotherapy: Dialectical Behavioural Therapy (DBT) module?
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We will be offering ECHO Ontario Psychotherapy Module 3: Developmental Trauma and Resilience in Spring 2025. Would you like to be contacted when registration for this module opens?
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Yes
No
ECHO Ontario Integrated Mental and Physical Health Note: This program is focused on complex conditions (i.e., multi-morbidity with physical and mental health issues) and has been developed with physicians and nurse practitioners in mind. Despite the intended target audience, other healthcare professionals are welcome to apply.
What would you hope to gain by participating in ECHO Ontario Integrated Mental and Physical Health?
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Provide a brief description of a current or recent case that you have found particularly complex and why:
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Is there anything else you would like to share with us regarding your application or this ECHO?
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ECHO Adult Intellectual & Developmental Disabilities: Autism Why are you interested in participating in an ECHO focused on Autistic Adults and Mental Health?
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Please indicate what types of living situations your clients typically live in.
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How would you rank your familiarity with autism in adulthood? Select one.
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How would you rank your familiarity with mental health? Select one.
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Most of the people you work with: Select one.
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Have intellectual disabilities and are currently receiving developmental services (through DSO)
Are primarily autistic adults who do not have intellectual disabilities
I work with both groups
What topics would you like to see addressed to help you best support autistic adults' mental health?
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Is there anything else you would like to share with us regarding your application or 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 presentation and will help you to prepare and submit this anonymized client case. 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?
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Yes
No
Do you have a case you would like to discuss during one of the ECHO sessions?
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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
If so, please provide a brief rationale:
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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.
Carefully review and check to indicate your agreement to the following statements.
I will participate in at least 60% of sessions.
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I agree
I cannot attend 60% of sessions
Please specify why:
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ECHO case presentations do not create or establish a provider-patient/client relationship between any Hub clinician and a patient whose case is presented.
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I agree
I've read the SOC, but have questions. Please contact me. I understand that the ECHO Ontario Mental Health Project team will require my agreement to this item from the SoC prior to my attendance in the session.
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.
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I agree
I've read the SOC, but have questions. Please contact me. I understand that the ECHO Ontario Mental Health Project team will require my agreement to this item from the SoC prior to my attendance in the session.
Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to my patients or clients.
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I agree
I've read the SOC, but have questions. Please contact me. I understand that the ECHO Ontario Mental Health Project team will require my agreement to this item from the SoC prior to my attendance in the session.
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 ONMH 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.
My participation data will be shared with the Ministry of Health, Ontario Superhub, and ECHO New Mexico as outlined in the Statement of Collaboration.
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I agree
I agree to have my data shared with the Ministry of Health and Ontario Superhub, but want to opt out of sharing with ECHO New Mexico.
I've read the SOC, but have questions. Please contact me.
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've read the SoC, but have questions and understand I will be contacted to discuss this prior to being enrolled in the program
Initial Here
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Please provide date:
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Today D-M-Y
We will set up videoconference orientation sessions prior the start of the programs. Information about case discussion, how to access the session, and website access will be provided during this orientation.
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I have participated in an ECHO program in the past and already feel oriented!
Monday, January 6, 2025 11:00 a.m. -12:00 p.m. EST
Thursday, January 16, 2025 1:00-2:00 p.m. EST
I cannot attend any of the dates listed above and I will need to be sent an orientation PDF package.
Please select the 'Submit' button below to complete your application.This application will be reviewed by our operations team and you can expect to receive an email regarding your application status in late December.
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