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First Name
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Last Name
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Personal Residence Postal Code (If you do not live in East Toronto, please choose "lives outside of East Toronto" or if you do not have a fixed address, please choose "no fixed address") Hint: Click the magnifying glass icon to search for your postal code.
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Email
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Organization
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Access Alliance Multicultural Health and Community Services
Across Boundaries
Albany Medical Clinic
Baycrest
Bridgepoint Family Health Team
CAMH***
Closing the Gap
COTA Health
Developmental Services Toronto Region
Dr. Mark Lachmann Medicine Professional Corporation
East End Community Health Centre
Flemingdon Health Centre
Fontbonne Ministries***
Fred Victor***
Habitat Services***
Hennick Bridgepoint Hospital
Home Instead
Houselink and Mainstay Community Housing***
Houses Opening Today Toronto***
LOFT***
Michael Garron Hospital
Mount Sinai Hospital
Ontario Health atHome
Philip Aziz Centre***
Providence Healthcare
Reconnect Health Services
S.R.T. MedStaff
Salvation Army***
Scarborough Academic Family Health Team
South East Toronto Family Health Team
South Riverdale Community Health Centre
Spectrum Health Care
St. Michael's Homes
St. Michael's Hospital
Sunnybrook Hospital
TAIBU Community Health Centre
The Neighbourhood Group
The Neighbourhood Organization
This is a test only - to be deleted when ICP is moved to prod
Toronto Community Paramedics
Toronto Seniors Housing Corporation***
University Health Network
University of Toronto***
VHA Home Healthcare
WoodGreen
x. Other***
Organization Name (Please Specify)
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Program Team
Active Living Services***
Assisted Living
BSOT - Behaviour Support Outreach Team
Caregiver Support***
CCIST - Comprehensive Care and Integration Specialist Team
CCIST - Comprehensive Care and Integration Specialist Team
COPA - Community Outreach Programs in Addiction
COSS - Crisis Outreach for Seniors
COSS - Crisis Outreach for Seniors
Counselling & Support Services Team
DECNET (Diabetes Education Community Network of East Toronto)
EastTCaN (East Toronto Care Network)
ED - Emergency Department
FOCUS
Full Circle
HATM - Health Access Taylor-Massey
HATM - Health Access Taylor-Massey
HATP - Health Access Thorncliffe Park
HATP - Health Access Thorncliffe Park
Home and Cluster Care
Living Well At Home***
MGH2Home
MGH2Home
MGH2Home
MGH2Home
Ontario Structured Psychotherapy Program
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
Other
RISE
Social Work
This is a test only - to be deleted after ICP moves to prod
TIP - Telemedicine IMPACT Plus
x-Other***
Role
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Access Administrator (AA) - EastTCaN
Administrator - ETHP Collaborate
Administrator - PCCRT
Behavior Support Specialist
Chiropodist/Podiatrist
Clinical Care Facilitator (CCF) - EastTCaN
Community Paramedic
Community Support Worker (including senior health and outreach workers)*
Homecare Coordinator
Homecare Service Provider
Housing Support Staff (excluding social workers)***
Manager, Supervisor, or Director*
Nurse Practitioner (NP) - primary care
Nurse Practitioner (NP) - x-other settings/specialties
Occupational Therapist (OT)
Pharmacist
Physician (MD) - emergency medicine
Physician (MD) - endocrinology
Physician (MD) - geriatrics
Physician (MD) - primary care
Physician (MD) - psychiatry/geriatric psychiatry
Physician (MD) - x-other settings/specialties
Physician Assistant (PA) - primary care
Physician Assistant (PA) - x-other settings/specialties
Physiotherapist (PT)
RD (Registered Dietitian)
Registered Nurse (RN) - footcare
Registered Nurse (RN) - mental health or geriatrics
Registered Nurse (RN) - x-other settings/specialties
Registered Practical Nurse (RPN)
Respiratory Therapist (RT)
Social Worker (SW) - Housing (including Senior Services Coordinators)***
Social Worker (SW) - x-other settings/specialties*
Speech-Language Pathologist (SLP)
SW (Social Worker) - Case Management (including CCIST, MGH2Home)
This is for testing only - to be deleted when ICP is moved to Prod
TIP (Telemedicine IMPACT Plus) Facilitator
x - Other (please specify)*
Other (Role)
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Purpose of Access
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1. Referring my client (to PCCRT or SMHC)
2. Submitting a case (for discussion at PCCRT or SMHC rounds)
3. Accessing my client's existing coordinated care plan (CCP)
4. Other (note: you will be contacted and asked to provide further details)
Manager/Supervisor (Email)
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