P.I.E.C.E.S. Online Forms - Pre-Program Assessment Form

NS Registration for P.I.E.C.E.S. New LTC Homes Program

Answer all of the questions on the form and click the submit button to complete the registration.

Note: Please enter valid information in every field.



	First Name:
	Last Name:
	E-Mail Address:
	Professional Designation:
	Position:

	Organization:
	Address 1:
	Address 2:
	City:
	Postal Code:
	Phone Number:		() - - - Ext:
	Fax Number:		() - - - Ext:

	Administrator/Manager First Name:
	Administrator/Manager Last Name:
	Administrator/Manager E-Mail Address:

	District
	Session

	Has someone from your organization participated in the one-day Enabler Core Essentials Program?

	If yes, name of Enabler Program Participant(s):

	Date of Enabler Program:

	Does the participant, requesting placement on the wait list, have responsibility for providing care to persons with complex cognitive/mental health problems resulting in the presentation of challenging behaviours?

	Does the participant, requesting placement on the wait list, have an active role in the day-to-day assessment, planning and/or delivery of care?

Note: An incomplete form will affect acceptance of your application! Double check to ensure there is valid information in every field before you click submit.