Aulneau Renewal Centre
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Before You Apply….
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Caregiver
Caregiver Form
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*
" indicates required fields
Participant’s Name
*
First
Last
Participant’s Legal Name (if different)
First
Last
Participant’s Birthdate
*
DD slash MM slash YYYY
Gender
*
Personal Pronouns
*
Race/Ethnicity (please check all categories that apply):
*
Black (African, African Canadian, Afro-Caribbean descent)
Caucasian (European descent)
East Asian (Chinese, Japanese, Korean, Taiwanese descent)
Indigenous (First Nations, Inuk/Inuit, Métis descent)
Latin American (Hispanic or Latin American descent)
Middle Eastern (Arab, Persian, West Asian descent {e.g., Afgan, Egyptian, Iranian, Kurdish, Lebanese, Turkish})
South Asian (South Asian descent {e.g., Bangladeshi, Indian, Indo-Caribbean, Sri Lankan})
Southeast Asian (Cambodian, Filipino, Indonesian, Thai, Vietnamese, or other Southeast Asian descent)
Other
Do not know
Prefer not to answer
Occupation:
Do you have any accessibility needs that you would like us to be aware of? If so, please let us know, and we will do our best to accommodate these.
Participant’s Primary Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Participant’s Primary Phone Number
*
Is it safe to leave a voice message?
*
Yes
No
Participant's Email
*
Consent to Correspond via Email
*
Yes
No
Name of the youth participant who will be attending the group with you:
*
What is your relationship to this youth participant?
*
Does your teen have an individual counsellor or therapist that they are currently working with?
*
Yes
No
If your teen does not currently have an individual counsellor/therapist, we recommend that all youth participants also attend weekly or biweekly individual therapy sessions with a therapist here at Aulneau Renewal Centre, in addition to attending weekly DBT skills group sessions. These sessions can be conducted in-person or virtually. Are you interested in signing your teen up for individual therapy?
*
Yes
No
They already have an individual therapist
Have you accessed services at Aulneau Renewal Centre before?
*
Yes
No
How did you hear about Aulneau Renewal Centre?
*
What do you hope will change for you and your family as a result of participating in this DBT skills group?
*
Additional questions/comments:
Thank you for your application! The next step is for us to determine your rate for services and method of payment.
Are you seeking coverage for services through agencies such as CFS, Jordan's Principle, etc.?
*
Yes
No
Do you have insurance or any other coverage for counselling services? Please note that if you choose to use your insurance plan, you will be billed at the rate of $25 per person per skills group session and $120 per individual therapy session, if your teen is also attending individual therapy. You will then be required to submit your receipt to your insurance provider for reimbursement, as we do not offer direct billing at Aulneau.
*
Yes
No
If you are covered by insurance, which professional designations are you covered for? (e.g., RSW, CCC, etc.)
*
If you are not using insurance or funding through outside agencies, your fees for service will be assessed on our sliding scale based on your household income and the number of dependents living with you. Please select your annual household income
*
$9,999 and under
$10,000 - $14,999
$15,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
$100,000 and over
Please select the number of people living in the home.
*
I am alone
One dependent and myself
Two dependents and myself
Three dependents and myself
There are five or more of us
Thank you for providing the above information. If you are accessing our sliding scale services, please note that to determine your session rate, you will be required to submit documentation verifying your household income. This documentation may include a Notice of Assessment, an EIA budget letter, or a letter from your employer. Our intake coordinator will be in touch with you upon receiving your application. If you have any questions about this, please feel free to let us know.
