MHFA Indication of Interest form

1

Name* This field is required.

First Name

Last Name

2

Professional Title* This field is required.

Administrative Staff

Clinic Manager

Dietician

Family Physician

Medical Assistant

Medical Technician

Nurse Practitioner (NP)

Operations Coordinator / Manager

Other Physician

Pharmacist

Physician Assistant (PA)

Physiotherapist

Registered Nurse (RN)

Other

3

Name of Institution/Organization* This field is required.

4

Email* This field is required.

example@example.com

5

What province are you located in?* This field is required.

Ontario

Alberta

6

Do you work in a patient facing role?

Yes

No, but I work directly with patient-facing staff

No

7

What is your primary work setting (e.g. Emergency, Family Health Team, Independent Practice)?* This field is required.

8

What specifically interests you about the Mental Health First Aid (MHFA) Training Initiative?* This field is required.

9

May we have your permission to to feature your anonymous quote about why your interested in MHFA Training in outreach materials that go to other health clinics?

YESNO

10

What are your expectations from this training?

11

On a scale of 0 to 10, how would you rate your current level of knowledge about mental health issues and interventions?* This field is required.

0: No knowledge

1-2: Very limited knowledge

3-4: Somewhat limited knowledge

5-6: Moderate knowledge

7-8: Good knowledge

9-10: Excellent knowledge

12

Do you have any specific requirements for the training to be more accessible or inclusive?

13

Are you available to attend the MHFA course on Wednesday March 27th and Wednesday April 3rd from 6-9pm?* This field is required.

YESNO

14

Which upcoming MHFA course are you able to attend* This field is required.

March 18th and March 25th from 6-9pm EST

April 24 and April 30th from 6-9pm EST

May 20 and May 21 from 6-9pm EST

Contact me for future dates

15

Would you like to be contacted for upcoming MHFA courses if you are unable to attend in March?* This field is required.

YESNO

16

Cancellation in case of extenuating circumstances* This field is required.Layla is offering this course as an initiative to support workers in healthcare settings. We incur a cost in delivering the program and we hold the seat for you. We kindly ask that you do your best to attend the training absent serious circumstances, and if need be provide cancellation notice within 1 week of course start date

17

Contacting You* This field is required.Your information will be stored securely and privately and only used to contact you about the training. Please note that the launch of this program is contingent on interest levels. At this time, we plan to offer the program, but it is not guaranteed. For more information, you can reach out to community@layla.care