Are you an Ontario-based healthcare provider?
* must provide value
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. https://canada.echoontario.ca/ .
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:
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)
MD (GP Psychotherapist)
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:
* must provide value
Please specify:
* must provide value
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
Name of Educational Institution (if possible, please avoid acronyms):
* must provide value
Educational Institution Address:
* must provide value
Educational Institution City:
* must provide value
Educational Institution Postal Code:
* must provide value
Which Ontario Health Region is your organization/institution a part of?
* must provide value
North East Region
North West Region
East Region
Central Region
Toronto Region
West Region
What type of setting(s) do you practice in?
* must provide value
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.
* 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
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:
* must provide value
What is the size of your organization or practice?
* must provide value
How many years have you been practicing?
* must provide value
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?
* must provide value
Yes
No
Which ECHO program(s)?
* must provide value
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 Fall 2024 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:
* must provide value
Will others from your team participate in this ECHO?
* must provide value
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?
* must provide value
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:
* must provide value
Please specify:
* must provide value
Please specify:
* must provide value
We are interested in supporting providers who may be working with underserved populations. Please describe the populations that you work with.
* must provide value
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.
* must provide value
Yes No
If no, please describe rationale:
* must provide value
Please note that your participation in this ECHO will include the following:
camh.echoontario.ca Which ECHO Ontario program(s) are you applying for?
Please note, for "PROGRAM AT CAPACITY ," all available spots have been filled. A
* must provide value
PROGRAM AT CAPACITY ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD (10 sessions - Thursdays from 12:00 - 2:00 p.m. EST, September 19, 2024 - November 28, 2024)
ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 2: Principles of Addictions Care (8 sessions - Wednesdays from 12:15 - 1:45 p.m. EST, October 9, 2024 - November 27, 2024)
ECHO Ontario Psychotherapy Module 1: Cognitive Behavioural Therapy (CBT) (12 sessions - Tuesdays from 1:00 - 2:30 pm EST, September 24, 2024 - December 10, 2024)
ECHO Ontario General Mental Health (23 sessions - Tuesdays from 2:00 - 4:00 p.m. EST, October 1, 2024 - March 25, 2025)
ECHO Ontario Adult Intellectual and Developmental Disabilities (6 sessions - Fridays from 9:30 - 11:00 a.m. EST, November 8, 2024 - December 13, 2024)
ECHO Ontario Trans and Gender Diverse Healthcare (16 sessions - Thursdays from 9:00 - 10:30 a.m. EST, October 10, 2024 - February 13, 2025)
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:
* must provide value
ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 2: Principles of Addictions Care ECHO Ontario Psychotherapy CBT ECHO Ontario General Mental Health ECHO Ontario Adult Intellectual and Developmental Disabilities ECHO Ontario Trans and Gender Diverse Healthcare
Choice 2:
* must provide value
ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 2: Principles of Addictions Care ECHO Ontario Psychotherapy CBT ECHO Ontario General Mental Health ECHO Ontario Adult Intellectual and Developmental Disabilities ECHO Ontario Trans and Gender Diverse Healthcare
Choice 3 (if applicable):
ECHO Ontario Obsessive Compulsive Disorder Module 2: Enhancing CBT Skills for OCD ECHO Ontario Addiction Medicine and Psychosocial Interventions Module 2: Principles of Addictions Care ECHO Ontario Psychotherapy CBT ECHO Ontario General Mental Health ECHO Ontario Adult Intellectual and Developmental Disabilities ECHO Ontario Trans and Gender Diverse Healthcare
Why are you interested in participating in ECHO Ontario Mental Health Programming? (select all that apply)
* must provide value
Please specify:
* must provide value
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?
* must provide value
Yes
No
Please tell us which training program(s) you have completed, and when (approx. month and year) you attended:
* must provide value
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.
How many clients living with OCD have you treated?
* must provide value
Are you currently working with clients living with OCD?
* must provide value
Yes
No
Do you use CBT with these OCD clients?
* must provide value
Yes
No
Are you using CBT to treat clients with other mental health or addictions disorders?
* must provide value
Yes
No
Please specify what kind of CBT techniques you are using with these OCD clients:
* must provide value
Please specify what CBT techniques you are using with these clients:
* must provide value
ECHO Ontario Addiction Medicine and Psychosocial Interventions (AMPI) Module 2: Principles of Addictions Care Note: This program has been developed with physicians and nurses in mind, as well as other health care and allied health professionals from interprofessional teams.
Module 2: Principles of Addictions Care will provide an overview of substance-specific interventions. Assessment and treatment (including pharmacological interventions) will be reviewed for a variety of substances use disorders including alcohol, cannabis, opioids, and stimulants.
Note: Module 1: Engaging Individuals in Evidence-based Care ran in Spring 2024, and new participants in Module 2 will be given access to slides from Module 1. Module 3: Concurrent Disorders and Complexity will run in Winter 2025.
Did you participate in ECHO AMPI Module 1 which ran from April - June 2024?
* must provide value
Yes
No
Why are you interested in participating in ECHO Ontario Addiction Medicine and Psychosocial Interventions: Principles of Addictions Care?
* must provide value
What are you interested in learning?
* must provide value
What sorts of challenges are you experiencing with providing addiction care?
* must provide value
ECHO Ontario Psychotherapy Module 2: Cognitive Behavioural Therapy (CBT) 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 CBT principles and strategies into their current practice.
Are you a member of one of the following colleges?
* must provide value
How often do you work with clients living with depression and/or anxiety?
* 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 training or education in Cognitive Behavioural Therapy (CBT)?
* must provide value
Yes
No
Please explain:
* must provide value
How often do you use Cognitive Behavioural Therapy (CBT) 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)
What are you hoping to gain from the ECHO Psychotherapy: Cognitive Behavioural Therapy (CBT) module?
* must provide value
We will be offering ECHO Ontario Psychotherapy Modules 2 and 3 in 2025. Please select the other ECHO Ontario Psychotherapy modules you are interested in:
* must provide value
ECHO Ontario General Mental Health Note: ECHO Ontario Mental Health aims to help healthcare providers build capacity in the treatment and management of various mental health and addiction disorders (e.g. OCD, Personality Disorders, Depression, ADHD). This is our longest running program at 23 weekly sessions and offers the broadest range in its curriculum topics.
Why are you interested in participating in ECHO Ontario Mental Health?
* must provide value
Approximately how many total referrals to psychiatrists did your organization make in the past year?
* must provide value
What is the average wait time for one of your patients to see a psychiatrist for a consultation? Please specific number in weeks (e.g. 18 weeks)
* must provide value
Do you currently refer to any other outreach psychiatry?
* must provide value
Please specify:
* must provide value
If you do refer to outreach psychiatry, to whom do you refer?
* must provide value
ECHO Adult Intellectual & 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 providers who are working in the developmental sector supporting individuals with mental health concerns.
Do you work with adults with intellectual and/or developmental disabilities?
* must provide value
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?
* must provide value
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
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
Is there anything else you would like to share with us regarding your application or this ECHO?
ECHO Ontario Trans and Gender Diverse Healthcare Note: This ECHO is intended for those who provide care, or wish to provide care, to trans and gender diverse clients. It will be beneficial for providers working with clients who have transition-related goals, including but not limited to hormone replacement therapy and gender-affirming surgeries. Some topics that will be presented during this program are: gender-affirming healthcare, increasing provider confidence in diagnosing gender dysphoria, affirmative psychotherapeutic approaches, unique considerations for youth, working with families of trans clients, hormone therapies, surgeries, and post-operative care. We welcome all Ontario-based healthcare providers to apply including social workers, case workers, psychotherapists, medical doctors, nurses etc.
Why are you interested in participating in ECHO Ontario Trans and Gender Diverse Healthcare?
* must provide value
Note: These questions are used to understand people’s backgrounds. Previous experience with trans and gender diverse care is not required.
Approximately how many trans and gender diverse clients do you see in your practice?
* must provide value
What proportion of your clients are trans or gender diverse?
* must provide value
What forms of care have you provided to trans and gender diverse clients? (e.g., therapy, case management groups, medical care, etc.)
* must provide value
Are you working with families of trans and gender diverse clients?
* must provide value
Yes
No
Are you currently prescribing hormone therapy in your practice?
* must provide value
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
If yes, what hormone therapy have you prescribed?
* must provide value
Have you referred for transition related surgery?
* must provide value
Yes No Not relevant to my practice
Have you followed patients after transition-related surgery (all disciplines)?
* must provide value
Yes No Not relevant to my practice
Approximately how many clients have you referred for transition related surgery?
* must provide value
What types of surgeries have you referred your clients to?
* must provide value
Which programs/providers have you made referrals to for gender-specific or transition-related care (e.g., endocrinologists, hospitals, clinics)?
* must provide value
Needs Assessment (Optional)
What topics are you interested in learning about?
What barriers, if any, have you had in providing care? (e.g. workplace and community barriers, lack of knowledge, lack of funding, political context etc.)
What would facilitate you providing care to trans and gender diverse clients?
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?
* must provide value
Yes
No
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
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.
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
I cannot attend 60% of sessions
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 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.
* must provide value
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.
* must provide value
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.
* must provide value
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.
* must provide value
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.
* 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
Initial Here
* must provide value
Please provide date:
* must provide value
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.
* must provide value
I have participated in an ECHO program in the past and already feel oriented!
Wednesday, September 11, 2024 at 10:00 a.m. - 11:00 a.m. EST
Monday, September 16, 2024 at 1:00 p.m. - 2:00 p.m. EST
Friday, September 27, 2024 at 11:00 a.m. - 12:00 p.m. EST
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.
