Motivational Interviewing Training - Pre-registration Form 2017

Please take a few minutes to complete this form.

Our programs are designed around gaps between best practices in patient care and the actual care our patients receive. Therefore our course planning process requires us to identify actual practice gaps identified by learners when designing our training events. This expectation is that the training will be designed to change learners' strategies (competence), or what learners actually do in practice (performance), or the impact on the patient or on healthcare (patient outcomes).

Thank you.

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* 1. Briefly describe the client population you work with

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* 2. What practice-based issues do you feel that you are not able to address appropriately or to your satisfaction?

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* 3. What are the patient and/or practice-based issues you want to address by completing this introduction to motivational interviewing course

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* 4. Why do these issues exist? for example, is there a lack of knowledge, or competence, or an issue with performance. (You may select more than one response)

Need for knowledge/new information about this specific topic

A need to improve competence (know when and how to apply new strategies in practice)

Improved performance such as the adoption of new skills and behaviours

Other (please specify)

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* 5. What do you want to change? (You may select more than one response )

Knowledge

Competence: (Knowledge + Strategy) ability to apply knowledge plus a strategy in practice when the opportunity presents

Performance-in-practice: the application of new strategies or skills in the practice setting

Patient Outcomes: self-reported or data supported improvements in patient outcomes as a result of performance imporvments

Other (please specify)

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* 6. What is the extent of your experience using motivational intervieiwng with clients/patients?

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* 7. Please indicate the healthcare practitioner roles you would like improve competence with as a result of this course. (you may select more than one response)

medical/clinical expert: applying medical/clinical knowledge, clinical skills, and professional attitudes in their provision of high-quality and safe patient-centred care.

Communicator: form relationships with patients and their families that facilitate the gathering and sharing of information essential for exemplary health care.

Collaborator: work effectively with other health care providers to provide safe,
high-quality patient care.

Health Advocate: contribute expertise and influence to improve health by working with the patients, communities, or populations they serve to determine and understand needs, develop partnerships, speak on behalf of others when needed, and support the mobilization of resources to effect change.

Leader/Manager: develop in collaboration with other health care leaders, a vision of a high-quality health care
system and take responsibility for effecting change to move the system toward the achievement of that vision

Scholar: demonstrate a lifelong commitment to excellence in practice through continuous learning,
the teaching of others, the evaluation of evidence and other resources, and contributions to scholarship.

Professional: committed to the health and well-being of individual patients and society through
ethical practice, high personal standards of behaviour, commitment to the profession, profession-led regulation,
and maintenance of personal health.

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* 8. Please list other practice-based quality of care issues that should be addressed in this course

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* 9. Please indicate your name and contact information

Name:

email:

Discipline

work/job title

Practice setting