Please fill out this form to register for any of the groups we offer. If the group you chose is not running you will be placed on a waitlist for the next time we have it running. If you have questions about any groups or the waitlist, please contact reception@aulneau.com and they will be able to find the answers. Please Note: Most of our groups have a fee that is charged to attend.

Which group are you wanting to register for?*

You have chosen to register for our DBT Program. This group is intended for teens and their caregivers. One registration form will need to be filled out by the youth (13 - 17) and one by the caregiver.

Please answer the following questions to register for an Anger Management group.

Please answer the following questions to register for the Cherish the Caregiver group.

Other was chosen, which group are you requesting or asking about?*

DBT Group: Are you the Youth or the Caregiver?*

This form is to be filled out by youth registrants (age 13 - 17) who are interested in participating in our upcoming DBT skills group at Aulneau Renewal Centre. If you are a parent or caregiver, please choose Caregiver in the dropdown for the previous question. This group may be beneficial for youth who often feel overwhelmed by their feelings and emotions, struggle with self-harm and/or thoughts of suicide, and are looking to develop or improve their social-emotional skills. This course is intended to teach skills in the following domains: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. This is a 24-week in-person group that is scheduled to run from Tuesday, September 27, 2022 to Tuesday, April 11, 2023. Sessions will be held weekly and will run from 6pm to 8pm. The cost for these teen sessions will be on a sliding scale and will be based on household income. If you have any questions about this, please feel free to contact Grace at grace.pagtakhan@aulneau.com.

This form is for caregivers and parents whose teens will be participating in the DBT skills group at Aulneau Renewal Centre. If there is more than one caregiver in the home, you are welcome to fill out this form multiple times. If you are a youth, please choose youth in the dropdown for the previous question. This group may be beneficial for youth who often feel overwhelmed by their feelings and emotions, struggle with self-harm and/or thoughts of suicide, and are looking to develop or improve their social-emotional skills. This course is intended to teach skills in the following domains: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. This is a 24-week in-person group that is scheduled to run from Tuesday, September 27, 2022 to Tuesday, April 11, 2023. Sessions will be held weekly and will run from 6pm to 8pm. The cost for these caregiver sessions will be on a sliding scale and will be based on household income. If you have any questions about this, please feel free to contact Grace at grace.pagtakhan@aulneau.com.

Name*

First Last

Legal Name (If different)*

Birthdate*

Gender*

Pronouns*

Sexuality

Address*

Street Address City Province Postal Code

Phone*

Is it ok to leave a voicemail?*

Yes
No

Email*

Do you consent to email correspondence?*

Yes
No

Name of emergency contact*

Relationship to emergency contact?*

Emergency contact's phone number*

Topics that are a concern for you at this time?*

Have you ever self-harmed or had urges to self-harm?*

Yes
No

Have you every had suicidal thoughts or urges? If so, have you ever attempted suicide?*

Have you ever had thoughts of harming others?*

Yes
No

What do you do when you feel stressed or overwhelmed?*

Do you currently have an individual counsellor or therapist?*

Yes
No

Who do you turn to when you need support?*

What are some of your strengths?*

What do you hope will change as a result of participating in the DBT skills group?*

Name of Youth participant*

Relationship to Youth participant*

We will be holding two groups simultaneously: one for youth participants and one for parents and caregivers. Are you interested in attending weekly sessions with your teen?*

Yes
No
Maybe

What do you hope will change as a result of participating in this group with your teen?*

How did you hear about Aulneau Renewal Centre?*

Have you accessed Services at Aulneau Renewal Centre before?*

Yes
No

Additional questions/comments

Group Registrations