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Questions followed by an * are required
Participant's (Parent) Name*
First Last
Participant's (Parent) Birthdate*
Gender*
Race/Ethnicity
Please check all categories that best identifies the person registering for services.
- Black (African, African Canadian, Afro-Caribbean descent)
- Caucasian (European descent)
- East Asian (Chinese, Japanese, Korean, Taiwanese descent)
- Indigenous (First Nations, Inuk/Inuit, Metis 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, Pakistani, Sri Lankan})
- Southeast Asian (Cambodian, Filipino, Indonesian, Thai, Vietnamese, or other Southeast Asian descent)
- Other
- Do not know
- Prefer not to answer
Personal Pronouns?
- she/her/hers
- he/him/his
- they/them/their
- no pronoun (please just use my name)
Participant's Primary Address*
Street Address Address Line 2 City Province Postal Code
Participant's Primary Phone Number*
Is it safe to leave a phone message?*
- Yes
- No
Participant's Email*
Consent To Correspond Via Email?*
- Yes
- No
Emergency Contact Person*
Emergency Contact Phone*
Emergency Contact Relationship?*
Where are you requesting services?*
- Winnipeg
- Steinbach
Would you prefer remote or in-person sessions*
(You can choose more than one option)
- I am available to have a video session
- I am available to have a phone session
- I am available to meet in my home
- I am available to meet in person (at the office)
Are you presently involved in any family or custody related legal proceedings?*
- Yes
- No
Is your child presently involved in any family or custody related legal proceedings?*
- Yes
- No
ARC is aware that there are limited resources in the community which are equipped to address situations where clients are involved in high-conflict separation or divorce proceedings. Unfortunately ARC is not equipped to fully support clients in all of the needs they may have in such situations. For this reason, ARC reserves the right to deny or terminate services where there are high-conflict divorce or separation legal proceedings underway. Please Note: Aulneau Renewal Centre employees cannot become involved in any active court proceedings on a clients behalf.
Guardianship & Custody*
Please indicate the present guardianship & custody arrangements.
- Child resides with both parents
- Child resides with one parent [I have primary care and control]
- Child resides in a joint custody arrangement
- Child reside with other relative(s) or caregiver(s) [we/I have primary care and control]
Please Note: If you are a caregiver applying on behalf of a child and have arranged joint custody we will require further documentation which will be sent to you upon the approval of this application.
Consent
I am authorizing the Aulneau Renewal Centre to send, request and receive information about me or any minors listed on this registration form. I agree that the information will be shared with the guardian listed below. I understand that I may revoke this consent at any time by sending a letter to the agency.
I give consent
Primary Guardian's Name*
First Last
Gender
Phone Number
Email Address
Relationship to the child(ren)*
Please indicate your relationship to your child(ren). You can choose more than one option.
- Biological Parent
- Foster Parent
- Adoptive Parent
- Relative
- Other
Individuals in the home*
Please provide us with some basic information about the other individuals who reside in the home.
First and Last Name Gender Birthdate Relationship
Is the participant already involved in other therapy services?*
- Yes
- No
If yes, would you be willing to sign off on a release of information form?*
- Yes
- No
Have you accessed services at Aulneau Renewal Centre before?*
- Yes
- No
How did you hear about Aulneau Renewal Centre?*
- Family Doctor
- School
- CFS
- MATC
- Other Counselling Agency
- Friend
- Family Member
- Social Media
- Online Search
- Family Conciliation
- I am a returning client
Please Note: If you have been referred to Aulneau from Family Conciliation, you are required to submit to us a copy of all documentation from their agency before your application for services will be considered.
Accessibility
Are there any safety concerns in your home or precautions a worker should take before entering your home? (Ex. Physical dangers/damage, allergies, pets, abusive family member, neighbourhood, etc.)
Please Note: The Aulneau Renewal Centre is committed to a positive environment in which all employees and clients are treated with compassion, respect, and dignity. Abuse and harassment in any form (verbal, emotional, physical or sexual) will not be tolerated and may result in a termination of services. We reserve the right to refuse services.

Thank you for providing us with that information. The following questions are to help us understand your reasons for requesting Parent Coaching at this time.
Are you currently having suicidal thoughts/ thoughts of harming yourself?*
- Yes
- No
Have you had suicidal thoughts/ thoughts of harming yourself in the past?*
- Yes
- No
Are you currently having thoughts of harming others?*
- Yes
- No
If you are in crisis and need to speak to someone, you can call the Klinic Crisis Line at 204-786-8686. If you are struggling with thoughts of harming yourself or others please call The Crisis Response Centre at 204-940-1781.
Please list up to 3 of your greatest concerns that you would like to address in parent coaching at this time.
Concern 1*
Concern 2
Concern 3
At Aulneau we strive to support wellness from a whole-person/holistic perspective. In addition to what was noted above, what do you hope will change in the following areas as a result of working with a Parent Coach?
Changes in Physical Health
Emotional Changes
Mental Health Changes
Spiritual Changes
What do you do when you feel stressed or overwhelmed?
Who do you turn to when you need support?
Please Note: Just as our clients reserve the right to terminate services, the Aulneau Renewal Centre (ARC) also reserves the right to terminate or deny services. There may be many reasons why ARC determines that we will need to deny or terminate services. In general, ARC strives to ensure that all of our services are professional and an appropriate fit for the needs of our clients. In situations where our ethics may be compromised--or where clients' needs extend beyond the services we are equipped to offer--we will refer to other agencies who are better equipped to support your needs.
Terms of Service
Terms of service*
- I acknowledge and confirm that I have read the Terms of Service.
Aulneau Renewal Centre is currently experiencing a waitlist for services. Our Intake Coordinator will be in touch with you via email once your application for services is received. It is highly recommended that you monitor your emails (including your spam folder) for communications on the next steps in the intake process.
CAPTCHA

First and Last Name	Gender	Birthdate	Relationship

Parent Coaching Registration

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Terms of Service