Participant’s Name*

First Last

Participant’s Legal Name (if different)

First Last

Participant’s Birthdate*

Gender*

Personal Pronouns*

Participant’s Primary Address*

Street Address Address Line 2 City Province Postal Code

Participant’s Primary Phone Number*

Is it safe to leave a voice message?*

Participant's Email*

Consent to Correspond via Email*

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?*

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?*

Have you had suicidal thoughts ot thoughts of harming yourself in the past?*

Are you currently having thoughts of harming others?*

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

Do you currently have an individual counsellor/therapist?*

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?*

Dealing With Difficult Emotions – A DBT Group for Youth 14-17