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Dealing With Difficult Emotions – A DBT Group for Youth 14-17
Please fill out the form below to register.
Participant’s Name
*
First
Last
Participant’s Legal Name (if different)
First
Last
Participant’s Birthdate
*
Date Format: DD slash MM slash YYYY
Gender
*
Personal Pronouns
*
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
Parent/Legal Guardian's Name
*
First
Last
Parent/Legal Guardian's Email Address
*
Parent/Legal Guardian's Phone Number
*
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
*
Emergency Contact Phone
*
Have you accessed services at Aulneau before?
*
Yes
No
How did you hear about Aulneau?
*
Topics that are a concern for you at this time
*
Are you currently having suicidal thoughts or thoughts of harming yourself?
*
Yes
No
Have you had suicidal thoughts ot thoughts of harming yourself in the past?
*
Yes
No
Are you currently having thoughts of harming others?
*
Yes
No
What do you do when you feel stressed or overwhelmed?
*
Do you currently have an individual counsellor/therapist?
*
Yes
No
Who do you turn to when you need support?
*
What are some of your strengths?
*
What do you think will change as a result of participating in this group?
*