Personal Information * First Name: * Last Name: Phone # (Mobile): Phone # (Business): * Email: Clinic Name: * City: * Province/State: Select ... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming * Postal/ZIP: * Country: * Designation: MD PT DC OT AT NP Other Other (Please Specify): * How did you hear about us?: Online search Social media Colleague Professional Association Conference/seminar Other Other (Please Specify): * Have you previously taken Shift's Level 1 Course? Yes No * Have you completed any additional Concussion education/training outside of Shift's program? Yes No Please Specify: * Are you currently a Shift Concussion Management Member? Yes No * Name as you would like it to appear on your Course Certificate (e.g. John Smith, DC) :
PRACTICE INFORMATION Help us learn more about your practice style, setting and healthcare team. How many Concussion cases do you typically see in a month?: 0-4 5-9 10-14 15-19 20-24 25-29 30+ Which healthcare disciplines currently work within your facility (select all that apply): Physiotherapist Chiropractor Massage Therapist Athletic Therapist Occupational Therapist Osteopath Physician (MD) Naturopath Other (please specify) Specify: As part of your multidisciplinary environment, which healthcare disciplines have you utilized or recommend to your concussion patients when needed (either within your own facility or outside in your community?) (select all that apply): Physiotherapist Osteopath RMT Chiropractor Optometrist Athletic Therapist Occupational Therapist Naturopath Psychologist Neuropsychologist Audiologist Speech and Language Pathologist Medical Specialties (eg. Neurologist, Ophthalmologist, Psychiatrist, Physiatrist) Other (please specify) Specify: Comments : Do you have a formal relationship when it comes to referrals, collaboration, inter or intra-office communication with any of the following professions (either within your own facility or outside in your community) as it pertains to concussion patients? (Ie. is there open and direct communication back and forth regarding a shared patient's rehabilitation plan) Physiotherapist Osteopath RMT Chiropractor Optometrist Athletic Therapist Occupational Therapist Naturopath Psychologist Neuropsychologist Audiologist Speech and Language Pathologist Medical Specialties (eg. Neurologist, Ophthalmologist, Psychiatrist, Physiatrist) Other (please specify) Specify: Comments : What is the duration of your initial concussion assessment appointment (in terms of direct contact with the patient)?: Less than 30 minutes 30 - 45 minutes 45 - 1 hour 1 hour or more Varies (Please provide comment) Do you have access to a gym space/rehab space in order to complete exercises/exertion testing and training for your patients (as discussed at Shift's introductory course)?: Yes, within my facility Yes, outside my facility No What is the duration of your follow-up post-injury patient visits (on average)?: 10 - 20 minutes 20 - 30 minutes 30 - 45 minutes 45 - 1 hour Varies (Please provide comment)
COURSE INFORMATION Which course(s) would you like to register for? (check all that apply) * Shift Concussion Management Training: Level 2 Vestibular and Ocular Rehabilitation Methods for Concussion: October 4 - 5, 2019 - Guelph, ON $600.00 + HST (or $300.00 + HST for returning Level 2 Provider) View course details Complex Case Management with Cervical Treatment Considerations: October 6, 2019 - Guelph, ON $350.00 + HST (or $175.00 + HST for returning Level 2 Provider) View course details Note: Practitioners wishing to become a recognized Level 2 Provider of Shift's Program MUST complete both “Vestibular and Ocular Rehabilitation for Concussion” AND Complex Case Management with Cervical Treatment Considerations” in their entirety. Contact us for more information on course agendas. COURSE REGISTRATION Category * Select Registration Category General (“I am working toward my Level 2 training/membership”) Returning (“I am currently a Level 2 member returning for continuing education”)
COURSE REGISTRATION Category * Select Registration Category General (“I am working toward my Level 2 training/membership”) Returning (“I am currently a Level 2 member returning for continuing education”)
MEMBERSHIP OPTION For those who successfully complete all Level 2 training requirements, participants have the option of becoming a Member and Recognized Level 2 Trained Provider of the Shift Concussion Management Program. If you are already a Level 1 Member, your membership will be rolled into the Level 2 category with no added cost to you. Health Professionals interested in joining Shift's Level 2 Provider network are required to successfully pass all exams. Membership Includes Membership access to Shift's online resources, clinic forms, rehab videos, newsletters, and marketing materials 50% off repeat attendance to future Shift Concussion courses Access to Shift Level 2 Provider logo Listing on Shift's “Find a Provider” map (highlighted as Level 2 Provider) Access to Shift's Clinic Support Team An ImPACT account (Immediate Post Concussion and Cognitive Testing) Access to Physiotec's Shift Concussion Module for home exercise prescription (physiotec.ca) - Optional Opportunity for greater involvement with Shift Concussion Management (contact us for more details)
Fees Associated with Membership Annual Membership Fees $250 I am interested in becoming a Level 2 Member Not right now Note: you will not be charged a Level 2 membership fee until you have successfully completed all Level 2 courses and exams.