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? 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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MD (Family Physician)
MD (Specialist)
Physician Assistant
Nurse Practitioner
Registered Nurse
Pharmacist
Psychologist
Social Worker
Case Worker
Occupational Therapist
Psychotherapist
Physiotherapist
Behaviour Analyst
Audiologist
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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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
Please specify:
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How many years have you been practicing?
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0-1 2-5 6-10 11-15 16-19 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?
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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Social media (i.e. Twitter, Facebook)
Workshop or conference
Communications from professional association (e.g. newsletter, bulletin)
Academic program
Email from ECHO Ontario
Word of mouth (e.g. colleague)
ECHO Ontario Website
CAMH website
Received a fax from CAMH Access
Other
Please specify which association you belong to:
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ECHO sessions require the use of both a webcam and microphone. Please ensure that you have access to these resources prior to our launch in Winter 2020.
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It is 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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Please note that your participation in this ECHO will include the following:
camh.echoontario.ca Which ECHO Ontario program(s) are you applying for? [Reminder: These programs run concurrently. If you select more than one, please be aware of the weekly commitments.] If "PROGRAM FULL" applications will be added to a waitlist
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PROGRAM FULL - ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD (Thursdays from 12:00 - 2:00pm, January 9, 2020 - March 12, 2020)
ECHO Ontario Trans and Gender Diverse Healthcare: Advanced Topics (Thursdays from 9:00 - 10:30am, February 6, 2020 - March 12, 2020)
ECHO Ontario Complex Patient Management (Fridays from 12:00 - 1:15 pm, January 10, 2020 - March 27, 2020)
PROGRAM FULL - ECHO Ontario Psychotherapy Module 2: Dialectical Behavioural Therapy (DBT) (Tuesdays from 9:00 - 10:30am, January 7, 2020 - March 31, 2020)
PROGRAM FULL - ECHO Ontario Adult Intellectual and Developmental Disabilities (Fridays from 9:30 - 11:00 am, January 10, 2020 - March 27, 2020)
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 Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Trans and Gender Diverse Healthcare: Advanced Topics ECHO Ontario Complex Patient Management ECHO Ontario Psychotherapy Module 2: Dialectical Behavioural Therapy (DBT) ECHO Ontario Adult Intellectual and Developmental Disabilities
Choice 2:
* must provide value
ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Trans and Gender Diverse Healthcare: Advanced Topics ECHO Ontario Complex Patient Management ECHO Ontario Psychotherapy Module 2: Dialectical Behavioural Therapy (DBT) ECHO Ontario Adult Intellectual and Developmental Disabilities
Choice 3 (if applicable):
ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Trans and Gender Diverse Healthcare: Advanced Topics ECHO Ontario Complex Patient Management ECHO Ontario Psychotherapy Module 2: Dialectical Behavioural Therapy (DBT) ECHO Ontario Adult Intellectual and Developmental Disabilities
If any of the above programs reach capacity, are interested in joining the following ongoing programs:
Would you like to be contacted for our future Spring 2020 program ECHO Ontario Developmental Trauma and Resilience?
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Yes
No
Why are you interested in participating in ECHO Ontario Mental Health Programming? (select all that apply)
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ECHO Ontario Obsessive Compulsive Disorder Note: This 10-session module is designed for individuals who have had basic training in Cognitive Behavioural Therapy (CBT). In addition to didactic lectures and case based learning, this module will also provide additional opportunities for engagement (e.g. role-play, demonstration of CBT skills, experiential learning, and opportunities for [limited] supervision) to help develop skills for working with the OCD population.
Have you completed a CBT training course?
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Yes
No
Please tell us which training programs you have completed, and the dates you attended:
Note: This module is intended for individuals who have completed CBT training. If you have not completed any kind of CBT training, please be aware that your enrollment in this course will not be guaranteed.
Are you currently working with clients living with OCD?
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Yes
No
Do you use CBT with these OCD clients?
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Yes
No
Are you using CBT to treat clients with other mental health or addictions disorders?
Yes
No
Please describe the kind of work you currently doing and how many OCD clients you have treated with CBT:
Please describe the kind of work you currently doing and how many clients you have treated with CBT:
ECHO Ontario Trans and Gender Diverse Healthcare Note: This program is open to past and current ECHO TGDH participants, as well as healthcare providers with competency working in the area of trans and gender diverse healthcare.
Why are you interested in participating in ECHO Ontario Trans and Gender Diverse Healthcare: Advanced Topics?
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Approximately how many trans and gender diverse clients do you see in your practice?
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What proportion of your clients are trans?
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Are you currently prescribing hormone therapy in your practice?
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Yes
I am not a prescribing health care practitioner, but others on my team prescribe hormone therapy
I am not a prescribing health care practitioner, and no one else on my team prescribes hormone therapy
Not applicable to my discipline
How many clients have you referred for transition related surgery?
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0 1-5 6-10 11-15 16-19 20+
Which programs/providers have you made referrals to for gender-specific or transition-related care (e.g., endocrinologists, hospitals, clinics)?
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ECHO Ontario Complex Patient Management 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 health care professionals are welcome to apply.
Why are you interested in participating in ECHO Ontario Complex Patient Management?
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What do you want to learn more about?
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Describe a current or recent case that you have found particularly complex:
ECHO Ontario Psychotherapy 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)
How often do you use Dialectical Behavioural Therapy (DBT) techniques in your practice?
* must provide value
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 experience with DBT?
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Yes
No
Please explain:
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ECHO Ontario Adult Intellectual and Developmental Disabilities Note: This ECHO is open to registrants working in both the mental health and developmental sectors. This ECHO will be beneficial for clinicians working in hospital and community mental health settings who see some individuals with developmental disabilities in their practice. It would also be of great value to clinicians who are working in the developmental sector supporting individuals with mental health concerns. Some topics that will be presented during this program are: understanding behaviour that challenges, suicide risk and safety planning; assessment of autism and FASD; and wellness and mental health promotion.
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?
* must provide value
What are you interested in learning?
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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?
ECHO Ontario Psychotherapy: Developmental Trauma-Focused Therapies (April 2020) Have you had any prior experience with Developmental Trauma-Focused therapies?
* must provide value
Yes
No
An important part of the ECHO model is to discuss real, complex patient cases, collectively ask pertinent questions, and develop recommendations for care. These cases are presented with client consent; 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:
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.
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.
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.
The ECHO team records sessions for educational purposes and occasionally takes photos for promotion. My photo will not be shared unless I give permission first.
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I agree
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.
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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 the Community of Practice website will be provided during this orientation.
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Wednesday, December 18, 2019 at 3:00-4:00PM
Monday, January 6, 2020 at 9:00-10:00AM
I cannot attend any of the dates listed above and I will need alternate arrangements.
I have already participated in an ECHO orientation session and already feel oriented!
This application will be reviewed by our operations team and your participation will be confirmed by December 13th, 2019.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.
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