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Mental Health and Addictions Pilot Project - Patient/Client/Family/Caregiver Expression of Interest

Pre-Screening Questionnaire

The Niagara Ontario Health Team - Équipe Santé Ontario Niagara (NOHT-ÉSON) is undertaking a project to understand better the current gaps in accessing community services and develop system solutions to address the emergency departments (ED) and urgent care centres (UCC) being the first points of contact for mental health and addictions-related (MHA) care.

As part of this initiative, we are seeking to engage with patients and clients, 18 to 25-year-olds from Fort Erie, who have visited an ED or UCC, as well as family and caregiver representatives of 18 to 25-year-olds from Fort Erie who have visited an ED or UCC to share their lived experiences.
1.I'm a(Required.)
2.What is the approximate age of the patient or client?  Or, if you are a family member or caregiver, please provide the person’s approximate age.(Required.)
3.Have you or your loved one accessed MHA-related care in an ED or UCC in Niagara in the last two years?(Required.)
4.If you answered Yes to the above question, which ED or UCC in Niagara did you or your loved one access for MHA-related care in the last two years?(Required.)
5.How did you arrive at the ED or UCC?(Required.)
6.At what time of day did you visit the ED or UCC?(Required.)
The following demographic questions are being collected to help us better understand the experiences of different populations across our region. You are not obligated to answer any questions you are not comfortable answering.
7.What is your gender?(Required.)
8.What is your sexual orientation?(Required.)
9.Housing status:(Required.)
10.If your mother tongue is neither French nor English, which of Canada’s two official languages are you more comfortable with?(Required.)
11.Immigrant or refugee identity(Required.)
12.Indigenous identity(Required.)
13.Ethnic background(Required.)
14.Highest education level completed(Required.)
15.Indicate whether you are living with any of the following disabilities. (Check all that apply.)(Required.)
16.Are you covered by the Ontario Health Insurance Plan? (Do you have an Ontario health card?)(Required.)
17.If not, do you have any other health insurance?(Required.)
18.Please provide your contact information so we can contact if you meet the eligibility criteria.(Required.)
Thank you for your interest in participating on this project. Once the pre-screening questionnaire is reviewed and eligibility criteria are met, a representative from the NOHT-ÉSON will follow up.