MMAP Mentor Log Question Title * 1. Mentor Name Alison Arnot Joel Bordman Lisa Bromley Yelena Chorny Sharon Cirone Michael Cord Ruth Dubin Andrew Everett Mike Franklyn Chris Giorshev Janel Gracey Iris Greenwald Greg Hariton Sheldon Hershkop Melissa Holowaty Paul Hoogeveen Doug Howard Roman Jovey Caroline Kargel Yasmin Keshavjee Sharon Koivu Wiplove Lamba Ken Lee Lisa Lefebvre Lionel Marks de Chabris David Marsh Robert McKay Patrick McSharry Sean Moore Greg Murphy David Murphy Cuong Ngo-Minh Arun Radhakrishnan Lori Regenstreif Kevin Rod Sandra Sas Leah Skory Melissa Snider-Adler Mireille St-Jean Victor Wong Question Title * 2. Please enter data from your mentee interaction below: Name of Mentee(s) Question Title * 3. Interaction Details Date of Interaction Date Question Title * 4. Number of Minutes Question Title * 5. Payable To: Name as Above Corporation Name: Question Title * 6. HST Applicable? No Yes, (provide HST number below) Question Title * 7. Method of Communication (choose all that apply) Email Face-to-Face Fax Telephone Portal Other (please specify) Question Title * 8. Context of Contact (choose all that apply) General Clinical Professional Issues Purely Educational (small group session) Urgent Situation Describe the Issue: Question Title * 9. Age of Individual in Case 0-18 (Child/Adolescent) 18-24 (Transitional Aged Youth) 24-65 (Adult) 65 + (Geriatric) N/A Question Title * 10. Reason of Contact (choose all that apply) Pharmacotherapy Treatment Review Counselling Skills Diagnostic Disability Related Issues Interviewing Approaches and Techniques Aggression/Violence Competence Ethical Issues Screening and Assessment Case Management/Access to Community Resources Psychological Issues Arising from Medical Concerns Medico-Legal Issues Conflict Management Approaches and Practices Question Title * 11. New or Repeat Patient New Patient Repeat Patient Question Title * 12. Case Complexity 1 (not difficult at all) 2 3 4 5 (very difficult) 1 (not difficult at all) 2 3 4 5 (very difficult) Question Title * 13. Clinical Issues (choose all that apply) Addictions: Alcohol Addictions: Drug Opioid Maintenance Therapy: Methadone Opioid Maintenance Therapy: Buprenorphine Attention Deficit Disorder Crisis Intervention Family Dysfunction Disorder Pain and Addictions Chronic Pain Management Pain Opioid Prescribing Other (please specify) Question Title * 14. Comments Question Title * 15. I confirm that this information is accurate (Please provide electronic signature by typing name below) Done