Which primary ECHO would you like to register for?Please select ONE from the list below here.
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ECHO IDD - An introduction (begins November 2021)
ECHO IDD - Next step/Advance (begins November 2021)
ECHO IDD - Resources and Resource navigation (begins February 2022)
ECHO IDD Psychiatric Care (begins March 2022)
Which elective ECHO would you like to register for, in addition to the primary ECHO you selected?You may select None, One or more. Please do not check the program that you have selected as your primary ECHO program track. Thank you!
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ECHO IDD - An introduction (begins November 2021)
ECHO IDD - Next step/Advance (begins November 2021)
ECHO IDD - Resources and Resource navigation (begins February 2022)
Not interested in an elective ECHO program
ECHO IDD Psychiatric Care (begins March 2022)
How did you hear about us?
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Word of mouth Forwarded invitation Referral Enroute ECHO IDD Wraparound website Professional association newsletter Conference or Professional meeting Flyer Other
Other, please specify how you heard about us
Miss Ms. Mrs. Mr. Dr. Other
Other, please specify salutation if desired:
First name:
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Last name:
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E-mail:
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Telephone number (Work)
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Telephone number (mobile)
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Practice setting:
(Please select all that apply)
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Home-based services
School
Community-based clinic/organization
Hospital
Other
Please select all that apply
Other practice setting, please specify:
Practice or organization name:
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Practice location street address:
(include personal address if not affiliated with an organization)
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City:
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Zipcode:
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Which county or counties do you work in?
(Please select all that apply)
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Adams
Asotin
Benton
Chelan
Clallam
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
Garfield
Grant
Grays Harbor
Island
Jefferson
King
Kitsap
Kittitas
Klickitat
Lewis
Lincoln
Mason
Okanogan
Pacific
Pend Oreille
Pierce
San Juan
Skagit
Skamania
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima
Please select all that apply
Education:
(Please select all that apply)
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High school diploma
Some college
Associate's degree
Bachelor's degree
Master's degree
Doctoral degree
Student
Other
Professional role:
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Credentials:
(BA, BS, MA, MSW, MHP, LMHC, RN, LPN, MD, PsycD, DNP, ARNP, etc.)
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How would you describe your race/ethnicity?
(please select all that apply)
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American Indian/Alaska Native
Asian - regional ancestry not specified
Central Asian
Eastern Asian
Southeastern Asian
South Asian
Black - regional ancestry not specified
Black - African American
Black - African Canadian
Black - East African
Black - Latin American
Black - West African
Hispanic, Latina(a)(x), Mexico and Central American
Hispanic, Latina(a)(x), Caribbean
Hispanic, Latina(a)(x), South American
Hispanic, Latina(a)(x), Spanish origin
Hispanic, Latina(a)(x) - regional ancestry not specified
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Prefer not to say
Prefer to self-describe
Please select all that apply
If Prefer to self-describe, please specify:
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Please indicate the specific racial, ethnic, and/or tribal group(s) that you identify with:
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Number of clients:
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Age range of clients:
(Please select all that apply)
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0 - 3
4 - 9
10 - 13
14 - 18
19 - 24
25 and above
Years (Please select all that apply)
Race/ethnicity of clients:
(Please select all that apply)
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American Indian/Alaska Native
Asian - regional ancestry not specified
Central Asian
Eastern Asian
Southeastern Asian
South Asian
Black - regional ancestry not specified
Black - African American
Black - African Canadian
Black - East African
Black - Latin American
Black - West African
Hispanic, Latina(a)(x), Central American
Hispanic, Latina(a)(x), Caribbean
Hispanic, Latina(a)(x), South American
Hispanic, Latina(a)(x), Spanish origin
Hispanic, Latina(a)(x) - regional ancestry not specified
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
Do not know
Other
Please select all that apply
Diagnosis 1
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Diagnosis 2
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Diagnosis 3
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Client barrier or challenge 1:
Client barrier or challenge 2:
Client barrier or challenge 3:
Client barrier or challenge 4:
Client barrier or challenge 5:
How far do clients travel to receive your services?
(e.g., miles, travel time)
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What types of support services are available in your community for clients with IDD and mental health needs and their families?
(e.g., speech-language, occupational therapy, applied behavioral analysis, individualized education plan, and others)
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Three to five challenges program staff face when working with clients with IDD and behavioral health needs and their families:
(e.g., sharing diagnosis with client and family, connecting to resources, lack of resources, engaging with parents)
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What are the issues and pitfalls with existing programs for clients with IDD and mental health needs?
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What additional services and resources would benefit children/youth with IDD and mental health needs and families you serve?
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How long have you been in practice?
(years)
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Years
Please describe specific training you have had for working with children and young adults with dual diagnosis (IDD and mental health).
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Please tell us why you are interested in participating in this teleECHO program:
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What topics would you like addressed in this teleECHO program?
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Please tell us about your short-term (2 years) professional goals and how you think this teleECHO program can help you accomplish those goals.
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Please tell us about your long-term (5 years or more) professional goals and how you think teleECHO program can help you accomplish those goals.
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Please include a copy of your resume.Note: Not to worry if you do not have a resume. You may upload a blank document in order to submit the registration.
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I agree