Nomination Form

In recognition of an individual, team, service or program leading outstanding seniors’ mental healthcare and integrative practice models, such as: interprofessional and interdisciplinary collaboration, integration of mental and physical health care, and/or support systems integration/navigation of older adults. Additional domains of activity can also include: exemplary teamwork, outstanding educational initiatives, innovative program development and/or initiatives to build a community of practice in seniors’ mental healthcare at a regional, provincial or national level.
 
Nominee Qualities:
  • leads outstanding seniors’ mental healthcare and integrative practice models at a regional, provincial or national level
  • has broad interprofessional and interdisciplinary collaboration with exemplary teamwork
  • integrates mental and physical health care
  • supports systems integration/navigation of older adults
  • offers outstanding educational or other creative initiatives
  • builds a community of practice in seniors’ mental healthcare
  • creates sustainable practices that will make a lasting difference
  • addresses a priority need in the community
  • invites inclusion and the voice of older adults, where appropriate
  • shares their work with others enabling replication or adaptation

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* 1. Name of Nominator

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* 2. E-mail of Nominator

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* 3. Phone number of Nominator

PLEASE TELL US ABOUT YOUR NOMINEE

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* 4. Nominee Name

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* 5. Is the Nominee...

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* 6. Contact Name of Nominee

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* 7. E-mail of Nominee

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* 8. Phone number of Nominee

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* 9. What area of the country does the Nominee serve?

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* 10. Please tell us about the Nominee and how they meet the award qualities. (maximum 500 words)

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* 11. Your nomination can include statements made by older adults or their caregivers who have been positively impacted by the work of the nominee.  Please feel free to upload a document that includes these statements.

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* 12. Your nomination can also include collaborating material such as formal program evaluations, program descriptions, pamphlets and/or client reviews of programs and services.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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Announcement and Recognition
The Award recipients will be selected over the summer and will be contacted by the end of August.  We will announce the recipients at the CAGP-CCSMH Annual Scientific Meeting in September.  If the recipient plans to attend the ASM, we can present the award live.  Following the ASM, the successful individual(s) and/or team(s) will be profiled in the CAGP newsletter and the CCSMH e-newsletter, website and social media.
Thank you for taking the time to make a nomination. 
It is so important for Canadians to learn about the great work being done
to promote the mental health of older adults!

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