Participant’s Name*

First Last

Participant’s Legal Name (if different)

First Last

Participant’s Birthdate*

Gender*

Personal Pronouns*

Race/Ethnicity*

Do you have any accessibility needs that you would like us to be aware of? If so, we will do our best to accommodate these.*

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?*

Yes
No

Participant's Email*

Consent to Correspond via Email*

Yes
No

We ask that all youth participants attend group sessions with at least one caregiver. Do you have someone who will be able to attend these DBT skills group sessions with you?*

Yes
No
Maybe

Name of your caregiver(s) who will be attending the group with you:*

What is your relationship to your attending caregiver(s)?*

Do you currently have an individual counsellor or therapist, and if so, what is their name?*

If you do not currently have an individual counsellor/therapist, we recommend that you 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. Would you be interested in connecting with an individual therapist at Aulneau?*

Yes
No
Already have an individual therapist

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

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

Have you ever had thoughts of harming others?*

What do you hope will change for you and your family as a result of participating in this DBT skills group?*

Thank you for filling out this application! We look forward to connecting with you and your family soon. If you have any additional questions/comments, please feel free to write them here.*

Youth

Youth Form