ECHO-Chicago Registration Form

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jXvFVBteQpxuUaYdysgaJ62zIZMP4LIuWV8mSN3oB

First time ECHO-Chicago participants, please complete the form below. Simply completing this form does not guarantee your spot in the series. A coordinator will be in touch to confirm your participation.

If you're a previous ECHO-Chicago participant, DO NOT complete this form. Please reach out to us at echo@bsd.uchicago.edu

If you're looking to gain access to resources for specific series, DO NOT complete this form. Please reach out to us at echo@bsd.uchicago.edu for assistance.

Have you participated in ECHO-Chicago before?

Yes

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Name

* must provide value

Credentials

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Email address

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Cell Phone number

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Organization Name

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Organization Address

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Organization City

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Organization State

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Please specify Other State

Organization Zipcode

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How did you hear about ECHO-Chicago?

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Specify conference or event

Specify social media

Specify professional listserv or email group

Specify academic journal/article

Specify other

Are you currently practicing and seeing patients/clients?

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Yes

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Which ECHO-Chicago series are you interested in? (check upto 3)

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Adolescent Health

Behavioral Health Integration- Systems Collaborative care

Behavioral Health - Adult Populations

Behavioral Health - Pediatric Populations

Childhood Adversity and Trauma

Diabetes

Geriatrics for PCP

Geriatrics for SNF

Hepatitis C

Hepatitis C in Pregnancy & Infants

Hypertension

Opioid Use Disorder

Opioid Use Disorder for Emergency Departments

Opioid Use Disorder and Pain Management for Older Adults

Pediatric ADHD

Pediatric Allergy & Asthma

Pediatric Obesity

Post-COVID

Serious Mental Illness

Suicide Prevention for Gatekeepers

Urinary Incontinence

Vision Impairment & Mitigation in Primary Care - Adult Populations

Vision Impairment & Mitigation in Primary Care - Pediatric Populations

Women's Health

Which ECHO-Chicago series would you like to register for?

* must provide value

Hypertension

Pediatric Allergy & Asthma

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Participants agree to:

Attend scheduled Zoom sessions and engage respectfully
Maintain confidentiality of all patient information
Retain full responsibility for patient care and clinical decisions regardless of recommendations provided by subject matter experts and other participants
Consent to being photographed and recorded during sessions

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I agree to these terms

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Would you like us to contact you about any of these future series when more information becomes available?

Adolescent Health

Addiction, Substance Use Disorders & Harm Reduction

Behavioral Health - Adult Populations

Child & Adolescent Behavioral Health

Child & Adolescent Weight Management

Childhood Adversity and Trauma

Common Pediatric Problems in Primary Care

Common Pediatric Problems in Schools

Diabetes

Geriatrics for PCP

Hypertension

Maternal Health

Opioid Use Disorder

Opioid Use Disorder and Pain Management for Older Adults

Pediatric ADHD

Pediatric Allergy & Asthma

Pediatric Behavioral Health - Middle Childhood (6-12 year olds)

Refugee & Migrant Health

Suicide Prevention for Gatekeepers

Weight Management for Adult Populations

Women's Health

Series coordinator

Admin

Aliza

Isa

Manuela

Morgan

Patrick

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Notes

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