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:
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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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
Waterloo Wellington
What type of setting(s) do you practice in?
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Urban
Rural
Both urban and rural
What is your primary profession? Select which best applies.
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Audiologist
Behaviour Analyst
Case Worker
Developmental Services Worker
MD (Family Physician)
MD (Specialist)
Nurse Practitioner
Occupational Therapist
Pharmacist
Physician Assistant
Physiotherapist
Psychologist
Psychotherapist
Registered Nurse
Social Worker
Speech Language Pathologist
Student
Other
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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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
Family Health Group
Family Health Organization
Family Health Team
Nurse Practitioner-led Clinic
Private Practice / Solo Practitioner
Residency
University/College Health Care Centre
Other
Please specify:
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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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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)
Other
Please specify which association you belong to:
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Please specify:
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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.
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?
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Yes No
If no, please describe rationale:
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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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Please note that ECHO Ontario Adult Intellectual and Developmental Disabilities will run every Friday from 9:30 - 11 a.m. EST from April 17, 2020 to May 22, 2020.
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
Registration is open on a first come, first serve basis. If the program is full, you will be placed on a waiting list and contacted when a spot becomes available.
NOTE: Visit our website at camh.echoontario.ca for more information about program curriculum.
Do you work with adults with intellectual and/or developmental disabilities?
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Yes
No
Not at this time
Not at this time, but I would like to in the future
Why are you interested in participating in ECHO Ontario Adult Intellectual and Developmental Disabilities?
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What are you interested in learning?
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Please indicate what types of living situations your clients typically live in.
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If other, please explain:
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How would you rank your familiarity with the Intellectual and Developmental Disabilities population? Select one.
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Not at all familiar
Slightly familiar
Somewhat familiar
Moderately familiar
Extremely familiar
How would you rank your familiarity with mental health? Select one.
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Not at all familiar
Slightly familiar
Somewhat familiar
Moderately familiar
Extremely familiar
Is there anything else you would like to share with us regarding your application or this ECHO?
In order to better understand your learning needs, we are conducting the following brief needs assessment. Please answer the questions below.
How has the current situation (i.e., COVID-19) affected you and your staff agency?
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If other, please specify:
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Which of the following kinds of supports and resources would help you meet the current needs of your clients (i.e., during this pandemic and physical distancing)?
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Real-time telephone supports (Help Line)
Real-time on-line supports (e.g., chat/messaging with general information, etc.)
Real-time on-line support from social service providers who know the client
Real-time on-line support from a healthcare provider who knows the client
Timely access to acute medical care, such as a family doctor or nurse, to avoid going to the hospital
Resources to support the social connection of people with developmental disabilities who are either quarantined or being told to implement physical distancing
Up-to-date information from the municipal, provincial, and federal levels, regarding public health initiatives (e.g., quarantine, physical distancing, testing, etc.)
Basic step-by-step instructions for how to properly implement physical distancing
Clear evidence-based instructions for how to properly implement physical distancing
Clear evidence-based instructions for when, and how, to effectively support a person being quarantined.
Adapted instructional materials (e.g., Easy Read, visual tools, etc.)
Adapted programming that people can access remotely
Information regarding accessible apps that clients can use to access supports or entertainment, or help meet their social needs
Tools to improve access and/or decrease vulnerability in healthcare settings
Other (please specify)
If other, please specify:
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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.
Please review the Statement of Collaboration.
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
Not sure due to schedule uncertainties, but I will attend as many sessions as possible
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 have scheduled videoconference orientation sessions on a couple dates in April 2020. Information about case discussion, how to access the session, and the Community of Practice website will be provided during this orientation.
Please select which session you would like to attend.
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I have participated in an ECHO program in the past and already feel oriented!
Wednesday, April 8, 2020 at 9:00-10:00AM
Monday, April 20, 2020 at 3:00-4:00PM
I cannot attend any of the dates listed above and I will need to be sent an orientation PDF package.
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. Applications from rural and underserved areas of the province will be prioritized, given Project ECHO's aim to reduce disparities in access to mental health services.