Virtual Indigenous Sharing Circles on Health in FL&A Registration

Thank you for your interest in attending a Virtual Indigenous Sharing Circle on Health in FL&A.

These Virtual Circles are being hosted by and for members of the Indigenous communities who live in and/or use health services in Frontenac, Lennox or Addington counties. This includes centres such as Kingston and Napanee.

While we appreciate interest and support from our non-Indigenous friends, families and allies these Circles are intended for Indigenous People as a space to share among ourselves. If you are non-Indigenous and have an interest in Indigenous peoples health and well being, (ie. have Indigenous children/family members etc), please contact us directly at youmatter@3things.ca.

You can learn more about these important Circles at www.3things.ca.

Please fill out this survey to get registered. A Zoom link will be sent to you following your registration.

Question Title

* 1. How do you self-identify?

First Nations (Status)

First Nations (Non-Status)

Métis

Inuit

Indigenous

Prefer to self-describe

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* 2. What best describes your gender?

Female

Male

Prefer not to say

Prefer to self-describe

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* 3. What best describes your age range?

Under 18

18 - 24

25 - 34

35 - 50

50 - 65

Over 65

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* 4. Do you currently have a primary care doctor, often known as a family doctor?

Yes

Unsure

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* 5. A Little About You

First Name

Last Name

City/Town

Postal Code

Mobile Number

Home / Office Number

Email Address

Organization (If applicable)

Job Title (if applicable)

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* 6. Which Circle would you like to attend? (Select all that apply.) A Zoom link will be shared with you within 24 hours of registration.

December 5th 2020 10:30 AM - 12:00 PM

December 8th 2020 6:30 PM - 8:00 PM

December 14th 2020 1:30 PM - 3:00 PM

I would like to organize one with Three Things for members of my Nation, community or organization

I would prefer to schedule a one on one virtual visit

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* 7. Have you previously heard of the development of the new Ontario Health Team in FL&A?

Yes

Unsure

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* 8. This is a focus area for the development of the OHT that is of interest to me:

	Strongly agree	Agree	Somewhat Agree	Neither agree nor disagree	Somewhat disagree	Disagree	Strongly disagree
Building Health Homes: Looking at how to create a team based model of care for each patient	Building Health Homes: Looking at how to create a team based model of care for each patient Strongly agree	Building Health Homes: Looking at how to create a team based model of care for each patient Agree	Building Health Homes: Looking at how to create a team based model of care for each patient Somewhat Agree	Building Health Homes: Looking at how to create a team based model of care for each patient Neither agree nor disagree	Building Health Homes: Looking at how to create a team based model of care for each patient Somewhat disagree	Building Health Homes: Looking at how to create a team based model of care for each patient Disagree	Building Health Homes: Looking at how to create a team based model of care for each patient Strongly disagree
Integration of Mental Health Supports into Primary Care: More seamless transition for supports	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Strongly agree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Agree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Somewhat Agree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Neither agree nor disagree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Somewhat disagree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Disagree	Integration of Mental Health Supports into Primary Care: More seamless transition for supports Strongly disagree
Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Strongly agree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Agree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Somewhat Agree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Neither agree nor disagree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Somewhat disagree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Disagree	Coordinated Hospital Discharge: Every patient discharged from hospital attached to a health home Strongly disagree
Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Strongly agree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Agree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Somewhat Agree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Neither agree nor disagree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Somewhat disagree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Disagree	Ageing well at home: Looking at how to keep people well in their homes; avoiding hospitalization Strongly disagree
Palliative care partnerships: Looking at palliative care and end of life transitions	Palliative care partnerships: Looking at palliative care and end of life transitions Strongly agree	Palliative care partnerships: Looking at palliative care and end of life transitions Agree	Palliative care partnerships: Looking at palliative care and end of life transitions Somewhat Agree	Palliative care partnerships: Looking at palliative care and end of life transitions Neither agree nor disagree	Palliative care partnerships: Looking at palliative care and end of life transitions Somewhat disagree	Palliative care partnerships: Looking at palliative care and end of life transitions Disagree	Palliative care partnerships: Looking at palliative care and end of life transitions Strongly disagree

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* 9. What topics would you most like to learn about or discuss at this event?

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* 10. How would you like to receive additional information about Virtual Indigenous Sharing Circles on Health in FL&A?

Text

Both