DBT Skills Courses Registration Form 2024

Group Members Information

We will collect the information of your group members. Each of your group members must complete the registration form, below information is for grouping purposes only.
Group Member 1 Full Name*

First NameLast Name
Group Member 1 Email*
example@example.com
Group Member 1 Phone Number*
Please enter a valid phone number.
Group Member 2 Full Name*

First NameLast Name
Group Member 2 Email*
example@example.com
Group Member 2 Phone Number*
Please enter a valid phone number.
Group Member 3 Full Name*

First NameLast Name
Group Member 3 Email*
example@example.com
Group Member 3 Phone Number*
Please enter a valid phone number.
Group Member 4 Full Name*

First NameLast Name
Group Member 4 Email*
example@example.com
Group Member 4 Phone Number*
Please enter a valid phone number.
Group Member 5 Full Name

First NameLast Name
Group Member 5 Email
example@example.com
Group Member 5 Phone Number
Please enter a valid phone number.
Group Member 6 Full Name

First NameLast Name
Group Member 6 Email
example@example.com
Group Member 6 Phone Number
Please enter a valid phone number.

Participation Agreement
1. I agree to uphold confidentiality - anything shared in the group is NOT to be shared outside the room. This includes no gossiping and not showing the computer screen to family members or friends. I promise to be in a private space when I am engaging in group therapy and not to record any of the sessions. I promise to inform the facilitators if I am attending any virtual session of this course from a location that is not the same as that used to register for the course, or is outside of Ontario.
Information disclosed by participants will be kept strictly confidential by the facilitators: Kathy Lam, Dr. Alice Chen and interns, and will not be revealed to any person outside of the group without permission.

Limits of Confidentiality
There are certain situations in which we are required by law to disclose information obtained. These situations are:
a. If you pose a threat of physical harm or death to yourself or to others, including danger of suicide or assault.
b. If the facilitator becomes aware of a situation of neglect or harm of a minor or an elderly individual.
c. If a court of law issues a legitimate subpoena, requiring the facilitator to disclose information.
d. If an issue arises and the facilitator needs to consult with another counselor or supervisor.
I understand and accept that the facilitators are bound by these professional ethics and laws and will take any necessary steps to ensure my safety and the safety of others.
2. I agree that in the event of an emergency that pertains to the welfare of my medical and psychological health, I will go to the nearest hospital emergency room or call 911.
3. I agree to respect every person’s contribution without judgement. We agree to encourage all participants to share their own feelings, and to not offer advice.
4. Personal information may be shared, however, so as not to trigger anyone in session, I agree to stay clear of details, and provide only the general feelings experienced.
4. I agree to respect every person’s privacy and right to refrain from participating or volunteering information, while recognizing that active involvement is of great benefit to the participant.
6. I agree to pay full attention and to listen carefully to others during the group meeting. This includes not interrupting, staying off my devices (i.e. not engaging in texting, social media, email, phone calls, gaming, browsing, etc.) and not carrying on side conversations during the session. I agree to mute all cell phones and other devices during the session.
7. I agree to arrive on time. I will attend each session to provide continuity and a safe environment for the group. If I cannot attend a session, I will let the facilitators know in advance.
8. I agree that I will not invite visitors or observers to our group.
9. I agree to engaging in virtual care and acknowledge the limits of using virtual programs for therapy for reasons such as suboptimal understanding/communication, interruptions due to technological and internet bandwidth.
10. I agree to the use of email and reported understanding of the risks and appropriate use of email.

11. Application fee is non-refundable. If participants cancel before/after the first session, the course fee will be prorated and can be kept as “credit” for future courses. A “credit’ will be valid for 24 months, starting from the date of your cancellation.
I have reviewed, understood and agreed to follow the above.*

Yes
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DBT Skills Course: Tame Your Emotional Rollercoaster - Term 1 Registration Form

Participant Information

OHIP Information

Private Insurance

Screening Consultation

Course Fees & Registration Screening

Group Members Information

Sponsorship Application

Participation Agreement