• Program Registration Form

    Program Registration Form

    Embodiment of ACT
  • Please review the following terms listed below. Note that your signature at the end of this documents indicates that all sections of the registration form for the Embodiment of ACT training have been read, understood, and you are in agreement with the terms and conditions as outlined within this document.

    If you have any further questions after reading, please contact the office at 905-904-0398 well in advance of the program start date.

     

    Please note this document contains the following sections:

    Part 1: Personal Information 
    Part 2: Statement of Understanding
    Part 3: Privacy & Confidentiality

     

    Naturally yours,
    Zenia Mihevc, BSW MSW RSW
    Clinical Director
    905-904-0398
    zenia@alittlezen.ca

  • Part 1: Personal Information

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  • Part 2: Statement of Understanding 

    Please read the following terms carefully. Your signature at the end of this document confirms that you have read, understood, and agreed to the terms and conditions outlined in this section.

     

    Payment and Receipts: A Little Zen will issue and invoice via email directly to each registered participant for their individual cost to attend the training.  Note that payment must be received in full at the time of registration to secure your spot.  Payments can be made through e-transfer to Payments@alittlezen.ca or by contacting the office for credit card payment.

     

    Missed/Cancelled/Late Policy: Please be advised that if you must cancel your participation in the training after registering and remitting payment, at least 5 business days of advanced notice is requested.  Note that if you provide notice of cancellation more than 5 business days in advance, 75% of the full amount will be refunded to you via interac e-transfer, as the difference is held back for admistrative purposes.  If you provide less than 5 business days of advanced notice, miss the training, do not show then no refund will be issued.  

     

    Attendance: Your presence at the entire training session is important and crucial. You must attend at minimum 80% of the training in order to receive your certificate of completion.  

     

    Participation: We will engage in various activities, including exploring concepts, experiential exercises, mindfulness exercises, where you will be invited to explore real life personal and professional experiences.  We  will invite you to bring you real life experiences to the program and encourage everyone to share their reactions to the topics discussed. The more you contribute to the group, the more you will gain from it.

    The training sessions will involve the facilitator presenting skills and concepts, group discussions, mindfulness exercises, and experiential exercises. We will approach thoughts and feelings in a different way than we are accustomed to. Initially, you may feel confused or uncomfortable, but we ask you to be open and willing to embrace this process. Understanding everything perfectly is not necessary to benefit from the program. Improvement may continue even after the program ends.

     

    Safety Considerations: Creating and maintaining a safe environment is crucial. Mutual respect and trust are vital elements. Please be respectful when sharing and discussing with fellow group members. Avoid insulting, criticizing, or interrupting others. The group facilitator will strive to maintain a respectful and safe environment. Disruptive or intoxicated individuals may be asked to refrain from participating or leave the group.

    As we get to know each other, personal details, feelings, and thoughts will be shared. Our usual response to someone's suffering is to try and alleviate their pain by offering solutions or reassurance. In this group, we will try not to engage in this "rescuing" behavior. Instead, we aim to face pain without letting it control us. While it may not fully make sense now, we will discuss it further as we progress through the group.

     

    Emergencies: Please note that your facilitator cannot provide crisis support during programs. In case of an emergency or crisis, please contact 911, an appropriate crisis line, or go to the nearest emergency department.

     

    Consent to engaging in embodiment and yogic practices: By participating in a Professional Training facilitated by Zenia Mihevc and/or Facilitators of A Little Zen, you acknowledge the potential risks of injury associated with physical movement and exercise.

    I understand by signing this agreement:

    • I acknowledge that by participating in this program includes embodiment and yoga practices and may include stretching, breathing exercises, and other physical movements;
    • I am aware that participation in these activities carries certain inherent risks of physical injury or harm;
    • I voluntarily choose to participate in embodiment and yogic practices with full knowledge of the potential risks involved;
    • I acknowledge that it is my responsibility to consult with a healthcare professional prior to participating in any embodiment and yogic practices to ensure that I am in good health and physically able to engage in the activities involved;
    • I agree to disclose any medical conditions, injuries, or limitations that may affect my ability to participate safely;
    • I release and discharge the program facilitator, Zenia Mihevc, A Little Zen and its directors, employees, and agents from any and all liability, claims, demands, or actions arising out of or in connection with my participation in embodiment and yogic practices, including but not limited to any injuries or damages that may occur as a result of negligence or fault of the facilitator or any other participant;
    • I agree to follow the instructions provided by the program facilitator and will not engage in any activities that are beyond my physical limitations or that may cause injury to myself or others;
    • I understand that I have the right to ask questions and seek clarification about any aspects of the program and I agree to communicate any concerns or discomfort to the facilitator during the sessions.
  • Part 3 Privacy & Confidentiality:

    Please carefully review the following terms. Your signature at the end of this document confirms that you have read, understood, and agreed to the terms and conditions outlined in this "Privacy & Confidentiality" section.

     

    Confidentiality: Maintaining confidentiality is essential. You are expected to keep the disclosures, personal information, and identities of other group members confidential. Initially, you may feel uncomfortable discussing personal matters, but we encourage your active participation and confidentiality. Please refrain from discussing other group members' matters outside the group, including their names. You may discuss your own experiences of the group while keeping others' information confidential. Your group facilitator will also maintain confidentiality of all group members' personal information discussed during the sessions.

     

    Note Taking & Record-Keeping: Taking notes is a necessary part of our work. These notes provide an interpretation of what happened and comply with professional regulations and requirements. Notes are recorded after each session and safely stored in A Little Zen's Client Management Software - Cliniko, which meets professional regulations.

     

    Limits of Confidentiality: There are exceptions when confidentiality cannot be maintained. These are exceptions are:

    • Reporting child abuse or ongoing abuse to the appropriate authorities is mandatory.
    • Reporting sexual assault by another regulated healthcare provider is required.
    • If you disclose plans of self-harm or harm to others, intervention is necessary for safety.
    • If your records are subpoenaed by a court, we are required to provide relevant documents or testimony for legal proceedings.
       
       
  • General Consent:

    I confirm that the "Personal Information", "Statement of Understanding", and "Privacy & Confidentiality" sections have been read, understood and I am in agreement with the terms and conditions, as outlined within this document. I have been given an opportunity to ask questions about this program and I am voluntarily participating in it.

     

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