CKO Peer Circles Participant Application Form

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* 1. Full name:

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* 2. CKO Registration number:

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* 3. Email address:

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* 4. Your practice information:
(Refer to CKO website for more details)

Clinical (Providing direct patient/client service or care)

Non-Clinical (Not providing direct patient/client service or care)

Mixed (Involving some elements of both)

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* 5. Each Peer Circle session will last for 1.5-2 hours. Participants are expected to meet four times over a six-month period from October 2023 to March 2024.

Morning (between 9 a.m. to 12 p.m.)

Afternoon (between 12 p.m. to 3 p.m.)

Evening (between 5 p.m. to 8 p.m.)

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* 6. The following topics will be covered in the upcoming Peer Circle cycle, please list your learning goals or needs for each topic.

Virtual Treatment, Care and Services:

Scope of Practice:

Consent:

Discharging a Patient/Client: