POSTGRADUATE PSYCHIATRY OFFICE:

							                       POSTGRADUATE PSYCHIATRY OFFICE:
                        IMG OBSERVER APPLICATION FORM


1. NAME OF APPLICANT:          ________________________________________________


2. APPLICANT EMAIL:            ________________________________________________


3. MEDICAL SCHOOL:             ________________________________________________


4. YEAR GRADUATED FROM MEDICAL SCHOOL: _________________________
       (Write “Pending” if still enrolled in medical school)

5. PREFERRED HOSPITAL SITE (Check all that apply):

 Baycrest
 Centre for Addiction and Mental Health
 Hincks-Dellcrest
 Mt. Sinai Hospital
 Ontario Shores
 St. Michael’s Hospital
 Sunnybrook Health Sciences Centre
 University Health Network (Toronto General Hospital /Toronto Western Hospital)


6. PREFERRED CLINICAL EXPOSURE
 Mood
 Addictions
 Geriatric
 Child
 Emergency Psychiatry
 General Outpatient
 General Inpatient
 Consultation-Liaison Psychiatry
 Psychosis
 Other (please specify) __________________________________________________


7. Preferred time period (specify one 4-week block) ____________________________________
Please return form by fax or email to either:


Julia Bella
Coordinator, Postgraduate Education and Fellowship Program
Department of Psychiatry, University of Toronto
CAMH – College Site
250 College St, Ste. 841
Toronto, ON M5T 1R8
Ph: 416-979-6911
Fax: 416-979-6928
Email: Julia.bella@utoronto.ca

Sandra Hummel
Assistant to Dr. Sockalingam (Director of IMG Training)
Department of Psychiatry, University Health Network
Toronto General Hospital – 8EN-228
Toronto, ON M5G 2C4
Ph: 416-340-3387
Fax: 416-340-4198
Email: Sandra.hummel@uhn.on.ca