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Provincial Mental Health and Substance Use ECHO Registration Form

Thank you for your interest in the Provincial Mental Health and Substance Use ECHO, hosted by BC Mental Health and Substance Use Services (BCMHSUS). As part of your registration, we would like to ask you a brief series of confidential questions to better understand and serve ECHO participants. Please use your business contact information if possible. Any reporting on the information you share in this form will be anonymized.

Participation in ECHO is voluntary. If you complete this form, you are consenting (agreeing) to participate. Please note that questions with an asterisk (*) must be completed in order to register. The information you share in the registration form is confidential. It will be accessed by the BCMHSUS ECHO team/technical support staff, and some information, limited to name, email address, and organization affiliation will also be shared with the University of New Mexico's Health Sciences Centre ECHO Institute, the creators of Project ECHO, located in New Mexico, USA. These questions are shared to support the growth of the ECHO model and will be used for research, communications, quality improvement, and decision-making.

Additionally, your email address will be shared with Howspace, an online learning platform which houses ECHO session materials and resources. Your email will be used to create a unique link through which you will access Howspace. Howspace will never share or disclose your information with third parties.

We are asking you to share personal information including your email address, geographic location, personal views/opinions, and gender (optional).

Your personal information is protected by the B.C. Freedom of Information and Protection of Privacy Act (FIPPA). Your information will be collected in accordance with section 26 (c) and (e) of FIPPA.

If you have questions about the survey or your information please contact echo_bcmhsus@phsa.ca

First name

* must provide value

Last name

* must provide value

Organization

* must provide value

Country

* must provide value

Canada

Other (please specify)

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If country is other, please specify country and province/state:

* must provide value

Province/Territory

* must provide value

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Nunavut

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

reset

City/Town

* must provide value

Why are you interested in joining the Provincial Mental Health and Substance Use ECHO? (please select all that apply)

To learn new knowledge that is applicable to my work/practice

To learn new knowledge that is applicable to my personal life

To network/interact with my colleagues/peers

To discuss my clients/patients with an interdisciplinary team/specialists

I was required to join as part of my work

A colleague recommended I join the Provincial Mental Health and Substance Use ECHO

I have had positive experiences participating in other ECHOs

Other (please specify)

Prefer not to answer

If reason is other, please specify:

What is your profession/role? (please select all that apply)

* must provide value

Academic researcher

Administrator/Manager/Leader

Counsellor (non-regulated health professional)

Counsellor (regulated health professional)

Educator

Family member of person with lived/living experience

Licensed Practical Nurse (LPN)

Nurse Practitioner (NP)

Occupational Therapist

Peer Support Worker

Person with lived/living experience

Personal Support Worker (PSW)

Psychologist

Physician - Family medicine/general practice

Physician - Psychiatry

Physician - Other speciality (please specify)

Physiotherapist

Registered Nurse (RN)

Registered Psychiatric Nurse (RPN)

Social Worker

Students and Post-doctoral Fellows

Other (please specify)

If specialty is other, please specify:

* must provide value

What is your profession/role? (Please select all that apply)

* must provide value

Administrator/manager/leader

Counsellor

Educator/learning specialist

Nurse (e.g. LPN, NP, RN, RPN)

Occupational therapist

Peer support worker

Person with lived/living experience (including family members)

Personal support worker (PSW)

Psychologist

Physician (e.g. general practice, psychiatry, other specialties)

Physiotherapist

Recreation therapist

Researcher

Social worker

Student

Other (please specify)

If profession/role is other, please specify:

* must provide value

Sector: (please select all that apply)

Criminal justice

Education

Housing (including supportive housing)

Mental health treatment services (including outreach services)

Substance use treatment services (including outreach services)

Integrated mental health and substance use treatment services (including outreach services)

Primary health care

Other health service (e.g., harm reduction, public health)

Social services (e.g., employment, financial)

Other (please specify)

If sector is other, please specify:

What specific population groups do your services target? (please select all that apply)

My practice does not target a specific population group

2SLGBTQI+ community

Children and youth

Adults

Older adults

Indigenous people

Individuals with low income

Individuals with precarious/no housing

People of Colour

Refugees, Immigrants, New Canadians

Other (please specify)

If population group is other, please specify:

Do you work for a regional or provincial health authority?

Yes

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If yes, please select all that apply:

First Nations Health Authority

Fraser Health

Interior Health

Island Health

Northern Health

Provincial Health Services Authority

Vancouver Coastal Health

Primary practice location: (please select all that apply)

* must provide value

Urban/suburban (an area with a population over 30,000 people)

Rural (an area with a population of less than 29,999 and more than 30 minutes from a community with a population greater than 30,000 people)

Remote (an area without year-round road access and/or relies on other mode of transportation to access suburban/urban centre for part or all of the year)

Other (please specify)

If practice location is other, please specify:

* must provide value

Which of Canada's official languages do you speak? (select all that apply)

French

English

Neither

Prefer not to answer

Please select the group(s) with which you identify: (select all that apply)

African (Nigeria, Ethiopia, Tanzania, etc.)

East Asian (China, Korea, Japan, Taiwan, etc.)

Eastern European (Poland, Hungary, Romania, Ukraine, Russia, etc.)

Middle Eastern (Israel, Syria, Jordan, Egypt, Iran, Iraq, etc.)

North American (Canada, United States)

Oceanic (Australia, Fiji, New Zealand, etc.)

South Asian (India, Afghanistan, Pakistan, Sri Lanka, etc.)

South/Central/Latin American (Argentina, Mexico, Brazil, etc.)

Southeast Asian (Thailand, Vietnam, Singapore, the Philippines, Indonesia, Cambodia, etc.)

Western European (UK, Spain, Portugal, France, Germany, Austria, Switzerland, etc.)

West Indian (Caribbean)

Other (please specify)

Prefer not to answer

If group is other, please specify:

Do you identify as Indigenous?

Yes

Do not know

Prefer not to answer

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Do you consider yourself to be (select all that apply):

Woman

Man

Trans woman

Trans man

Two-spirit

Non-binary (i.e., gender fluid, gender queer)

Other (please specify):

Prefer not to answer

If gender is other, please specify:

How did you learn about the Provincial Mental Health and Substance Use ECHO?

Another Project ECHO

BCMHSUS website

BC Provincial Mental Health and Substance Use Network newsletter

Conference/Presentation

Email campaign

Friend or colleague

Twitter

Don't remember/can't recall

Prefer not to answer

Other (please specify):

If other, please specify:

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.