Registration for Resilient Minds Group

Registration for Resilient Minds Group

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Thank you for your interest in ACT Learning Centre's Resilient Minds group program. The intention of this group program is to help children build upon emotional awareness and self-regulation skills through a combination of psychoeducation discussions, sensory exploration, mindfulness, and creative activities. Participants must be between the age of 7-9 years old and who can engage in reciprocal conversation. Please note that this group is only available in English.

Program Details

Dates:	Every Thursday starting on September 18, 2025 and ending on October 23, 2025.
Time:	5:00 pm to 6:30 pm
Location:	106 Colonnade Road, Ottawa
Duration:	The program runs for 6 weeks and each session will be 1.5 hours.
Cost:	$900

Registration

Please complete the following registration package. If you are registering for more than one (1) child, a separate registration form will be required for each. Simply refresh this webpage after you have submitted the first registration to start a new one.
Screening Appointment

Following your registration confirmation, you will be contacted by Amanda Black, Registered Psychotherapist (Qualifying) within 2 business days to schedule a brief intake telephone call. This will allow Amanda Black to discuss more details on the group program as well as to determine your child's eligibility.
Instructions

Please note that this registration package contains many mandatory fields. If you receive an error message, please scroll through the page to locate the missing field (indicated in red).

Once you have submitted your completed registration package, you will receive a confirmation email. Please check your junk or spam folder if you do not receive this confirmation. A representative from ACT's Intake Department will contact you within 2 business days following the submission of your completed package to discuss the next steps.

If at anytime during the registration process you have any questions, would like additional information, or if you have any difficulty completing this electronic form, please contact ACT Learning Centre’s Intake Department. Intake representatives are available Monday to Friday from 8:00 a.m. to 5:00 p.m. and can be reached by telephone at (343) 887-2287 (local) or (833) 887-7529 (toll-free) or by email at intake@actlearningcentre.ca.

Registration for Resilient Minds Group

* Denotes a required field
Custody and Decision-Making
For families who are divorced, separated, or going through any form of legal matters pertaining to custody and/or decision-making of the client being onboarded for services, ACT Learning Centre must be informed of whether one or both caregivers need to provide consent for services for the client. For families with decision-making agreements or parenting plans, please make a selection below on your decision-making situation.

If this does not apply to you, please select "The client lives with both caregivers and there is no agreement required or in place".

Please note:

If you select joint decision-making responsibility, you will be required to provide details for both caregivers on the Caregiver Information page. All future communications from ACT Learning Centre will be provided to both caregivers unless otherwise indicated in the Consent to Electronic Communications section of this registration package.

If you select sole decision-making responsibility, you will be required to upload any pertaining legal documentation below in order to confirm the sole decision-making status with ACT Learning Centre. All future communications from ACT Learning Centre will be provided to the sole caregiver selected unless otherwise indicated in the Consent to Electronic Communications section of this registration package.
Please indicate which caregiver has decision-making responsibility:*

The client lives with both caregivers and there is no agreement required or in placeBoth the primary and secondary caregivers have joint decision-making responsibilityThe primary caregiver has sole decision-making responsibilityThe secondary caregiver has sole decision-making responsibility
Do you have your legal documentation on hand readily available to upload and confirm the sole decision-making status?*

YesNo
Please ensure to provide this documentation at your earliest opportunity. You can email your documents to ACT's Intake Department at intake@actlearningcentre.ca.
Please upload the pertaining legal documentation to confirm the sole decision-making status.*

pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
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Are there any disputes between the caregivers regarding decision making?*

YesNo
Note: If the answer is 'Yes', where there are disputes relating to joint decision-making, ACT reserves the right to request a copy of the agreement of the decision of the court and inform the caregiver that a member of the ACT team will be in touch to discuss receiving a copy of the agreement. In the event that decision-making caregivers do not agree (i.e. one caregiver wants the client to receive services from ACT and one caregiver does not) the matter will be referred to the CEO of ACT for follow-up and registration will be placed on hold.
ACT's Policy for Obtaining Consent from Caregivers with Decision-Making Authority
Caregivers with decision-making authority should each sign a consent to treat form. If ACT has been provided with the contact information for the second caregiver with decision-making authority, we will attempt to contact that caregiver. Assessment and/or intervention can be initiated with consent from one caregiver with decision-making authority, however, it is ACT's policy to make every effort to receive consent from both caregivers with decision-making authority.

Where decision-making authority is joint, the authority to consent to treatment may be exercised by either caregiver on the client’s behalf.

Where decision-making authority is joint but the other caregiver has final decision-making authority, ACT will request consent from both caregivers.
ACT’s Policy and Procedure for Sharing Information with Caregivers with Decision-Making Authority
If the contact information for both caregivers is provided, ACT will provide updates, reports and emails to both caregivers.

If the contact information for only one caregiver has been provided, ACT will provide updates, reports and emails to that caregiver, however, if the second caregiver requests information, it is ACT's policy to provide it as per the above.

If caregivers are separated and do not yet have a joint decision-making agreement, both caregivers will receive information as per the above.

If the joint decision-making agreement is under dispute, both caregivers will receive information as per the above.
Please sign to confirm that you have read and acknowledge ACT Learning Centre's Custody and Decision-Making Policy.*

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Registration for Resilient Minds Group

* Denotes a required field
Caregiver Information
Primary Caregiver
Name*

First NameLast Name
Email*
Relationship to the client*
Primary Phone*
Secondary Phone
Does the primary caregiver reside at the same address as the client?*

YesNo
Street Address*
City*
Province*
Postal Code*
Would you like to add another caregiver?*

YesNo
You have selected ioint decision-making responsibility. As per ACT's Custody and Decision-Making policy, you are required to provide details for both caregivers. Please provide the contact details for the secondary caregiver below.
Secondary Caregiver
Name*

First NameLast Name
Email*
Relationship to the client*
Primary Phone*
Secondary Phone
Does the secondary caregiver live at the same address as the primary caregiver?*

YesNo
Street Address*
City*
Province*
Postal Code*

	Select
Self-injurious behaviours
PICA (eating disorder in which a person eats non-edibles)
Aggression towards others
Property destruction
Mouthing objects
Other challenging behaviours (please provide details)
Not applicable

	Select
EpiPen Jr® 0.15 mg
EpiPen® 0.3 mg
ALLERJECT® 0.15 mg
ALLERJECT® 0.3 mg
EmeradeTM 0.3 mg
EmeradeTM 0.5 mg

	Select
Previous anaphylactic reaction: Person is at greater risk.
Asthmatic: Person is at greater risk. If person is having a reaction and has difficulty breathing, give epinephrine auto-injector before asthma medication.

	Select
Cold / Flu
Hot or cold weather
Physical activity
Strong smells
Pollen
Pets
Anaphylaxis (specify details below)
Allergies (specify details below)
Other triggers (specify details below)

	Details
Name of the Medication
Dosage (number of puffs)

	Select
The client requires assistance to access and use reliever inhaler
The client can carry and administer the inhaler as needed without assistance

	Name	Phone Number
Primary Healthcare Provider

	Name	Phone Number	Role / Profession
Please provide details:

	Select
Change in weather
Changes in diet
Electronic stimulation (TV, videos, fluorescent lights)
Hormonal fluctuations
Illness
Improper medication balance
Inactivity
Lack of sleep
Stress
Other

	Provide Details:
Symptoms
Action to Take
Frequency of Seizures
Duration of Seizures
Date of Last Seizure (approx.)

	Provide Details:
Symptoms
Action to Take
Frequency of Seizures
Duration of Seizures
Date of Last Seizure (approx.)

	Provide Details:
Symptoms
Action to Take
Frequency of Seizures
Duration of Seizures
Date of Last Seizure (approx.)

	Details:
Name of Medication
Prescription Number
Dosage
Time of Administration
Instructions for Administration
Duration of Medication Regime
Possible Side Effects

	Select
I/We authorize ACT Learning Centre staff to administer prescribed medication to the client as prescribed. I/We understand understand that ACT staff are not medically trained to administer medication and I/we assume responsibility for any adverse reaction that might occur following the administration of medication.
The client is capable of administering their own medication. I/We bear sole responsibility for any adverse reaction that might occur following the self-administration of medication.
I/We confirm that the information herein is accurate and up to date. I/We understand that I/we must re-submit this form in case of any changes to the client's medication, condition, level of independence, or treatment plan.

Registration for Resilient Minds Group

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The following pages contain policies and consent forms which are mandatory for all clients being onboarded for services with ACT Learning Centre. If you have any questions regarding these policies and/or consent forms, you can discuss with your therapist during your initial consult/session. Please note that these policies may be amended with the approval of ACT Management. You will be notified of any changes before they take effect.

Registration for Resilient Minds Group

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Payment Policy
Payment is due on the receipt of your invoice.

Fees for each group may be eligible to be covered through the Ontario Autism Program (OAP) and/or Special Services at Home (SSAH). If you do not have funding from the OAP or SSAH, please contact your third-party health insurance provider (e.g., Great-West Life, Canada Life, Manulife, etc.) to inquire about your coverage and whether the fees are eligible.

To facilitate the payment process, ACT Learning Centre accepts MasterCard, Visa, e-transfer, and cheque. Invoices are provided via email. If you have any invoicing or payment inquiries, please contact our finance department at billing@actlearningcentre.ca.
Payment Procedures

If paying by credit card: Click on the Review and Pay button in the body of the email containing your invoice and enter your credit card information.

If paying by e-transfer: Send your e-transfer to accrec@actlearningcentre.ca indicating the invoice number in the e-transfer message.

If paying by cheque: Send by mail to ACT Learning Centre, 2723 Lancaster Rd. Suite 202, Ottawa, Ontario K1B 0B1. Please ensure to write the invoice number you are paying in the cheque memo section.

Overdue Payments: A member of ACT’s finance team will contact you about overdue invoices to arrange payment. If invoices are more than 60 days overdue without a payment agreement in place with ACT, the outstanding balance may be billed to the credit card on file.

Fees for group programs is charged as a lump sum and payable before the group begins. Missed sessions will not be refunded. When the client returns to the group after an absence, any handouts or homework activities that you they may have missed will be provided to you.
Group Program Payment Policy

All fees for group programs will be charged as a lump sum and payable before the group begins. Missed sessions will not be refunded. When the client returns to the group after an absence, any handouts or homework activities that you they may have missed will be provided to you.
I, Caregiver's First Name* Caregiver's Last Name* , understand that by signing this form, I am committing that the client, Client's First Name* Client's Last Name* will participate in the group program selected and I acknowledge that the payment made for this group program is non-refundable, regardless of whether I attend all the sessions or not.
Pre-Authorized Credit Card Policy

ACT Learning Centre collects credit card information from all clients/caregivers for the sole purpose of collecting any outstanding balance on your account, as per our payment policy for new clients.

ACT Learning Centre agrees to utilize the personal information provided for the sole purposes defined and to have in place reasonable security precautions to safeguard the aforementioned personal information.

Due to the terms and conditions of the electronic platform used (Jotform), we are unable to collect credit card information through this electronic form. After you have submitted your form, you will be contacted by a member of our finance team by email who will provide you with a form to collect your credit card information.
Please check this box in the event you do not have a credit card in your name to put on file.
Please sign to confirm that you have read and acknowledge ACT Learning Centre's Payment Policy.*

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Please use your mouse to sign if you are using a computer or your finger if you are using a mobile device.

Registration for Resilient Minds Group

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Third Party Health Insurance Policy
It is the responsibility of all caregivers/clients to make sure their invoice is accepted by their extended health insurance company such as Great West Life, Canada Life, Manulife, etc.

Caregivers/clients are responsible for paying for services rendered regardless of coverage by a third party funder. ACT Learning Centre does not offer direct billing to insurance companies.

Invoices for services will include the following:
- Name of the client
- Date of service
- Description of services
- Costs for services
- Service provider details including registration number of the regulated health professional (RHP)
Please check this box to indicate that you have read and agree with the above information regarding third party health insurance*

I acknowledge
For clients using third party health insurance providers, please indicate if you provide consent to ACT Learning Centre to disclose or exchange personal information relating to the client’s services. This may include invoices, when relevant and necessary, for the purpose of claims administration.*

YesNoNot applicable

Registration for Resilient Minds Group

* Denotes a required field
Nut-Free Policy
ACT Learning Centre strives to provide a safe environment for all our clients and staff. Therefore, to remain aligned with our Health and Safety duties, ACT programs and sites are 100% “nut-free” environments.

We kindly ask you not to send any food items containing peanuts, nuts, peanut butter, nut butter, or peanut products. Clients who are allergic to tree nut products do not need to ingest them to have a severe reaction. For example, touching surfaces or items that have been in contact with nuts/peanuts can cause a severe reaction.

Please speak with the client about allergies and encourage them not to share food with other client's in the centre. The ACT team will do the same by monitoring clients while they eat and having similar discussions with them while at the centre.
Please sign to confirm that you have read and acknowledge ACT Learning Centre's Nut Free Policy.*

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Registration for Resilient Minds Group

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Pick-Up and Emergency Contacts
Contacts Authorized for Pick-Up

Please share the names and contact information for anyone who may pick-up the client from ACT Learning Centre other than the Caregiver(s) listed previously (e.g., a grandparent, babysitter, friend, etc.). It is assumed that the Caregiver(s) have authorization to pick up the client unless stated otherwise below.

* Please note that any individual picking up the client may be required to show photo ID.
Who can pick up the client from ACT Learning Centre:*

ONLY the caregivers listed previouslyThe caregivers listed previously AND the individuals listed belowONLY the individuals listed below (please list in order of priority)

Emergency Contacts

Please share the names and contact information for anyone who you would like to list as an emergency contact other than the Caregiver(s) listed previously. It is assumed that the Caregiver(s) would be the first point of contact in an emergency unless stated otherwise below.
Who should be called first in the event of an emergency during your child / teen's appointments in our clinics?*

Call the caregivers first.Call the emergency contacts listed below first (please list in order of priority)

Emergency contacts:

	Name	Relation	Primary Phone	Secondary Phone
1
2
3

Registration for Resilient Minds Group

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Additional Information
Snack

Your child / teen is encouraged to bring a snack and water or another drink to each group session. Please note that all of ACT's clinics are a nut-free environment.

Transportation

The family is responsible for transportation to and from group therapy sessions. It is important that you indicate on the registration form who is approved to pick up your child / teen as photo ID may be requested.

Illness

ACT requests that all caregivers provide as much notice as possible when your child / teen is sick and will not be attending their scheduled group session. Should the therapist or staff note any of the below-mentioned symptoms during a session, we reserve the right to cancel immediately. The child / teen may return to their sessions or programming once they have been 24 hours symptom free. If your child / teen demonstrate any COVID-19 symptoms (even if mild), it is recommended that they stay home (self-isolate) while they are sick. Once there is no fever and the symptoms are improving for at least 24 hours (or 48 hours if they have gastrointestinal symptoms such as vomiting and/or diarrhea) they can then return to in-clinic services.
- COVID-19
- Fever of 101° or higher
- Excessive coughing (productive cough)
- Lethargy
- Vomiting
- Diarrhea
- Runny nose (green or yellow mucus)
- Pink eye
Please call or email Amanda Black, Registered Psychotherapist (Qualifying) to report any absences.
If your child / teen is not feeling well, please do not bring them to the centre.
Thank you for your continued support and cooperation.

Telephone: (613) 558-0980
Email: ablack@actlearningcentre.ca

Registration for Resilient Minds Group

* Denotes a required field
Waiver of Liability and Acceptance
Thank you for taking the time to complete the registration for group programs. A representative from ACT's Intake Department will review the registration information and contact you within 2 business days to discuss the next steps for onboarding.

If you are ready to submit your completed form, click on the purple SUBMIT button at the bottom of this page. If your submission was successful, you will receive an email confirmation from ACT Learning Centre Central Intake with the subject line of "Thank you - Merci". If you do not receive this email, please check your spam/junk folder.

To save or print your completed form for your records, click on the green PRINT button at the bottom of this page. The printer dialogue box will open and you can then either print the pages or save to your computer or mobile device as a PDF file.

If you have any questions or for additional information, please contact ACT Learning Centre’s Intake Department. Intake representatives are available Monday to Friday from 8:00 a.m. to 5:00 p.m. and can be reached by telephone at (343) 887-2287 (local) or (833) 887-7529 (toll-free) or by email at intake@actlearningcentre.ca.

Please review the statements below and indicate your acknowledgement by checking each box below.*

	I have read and acknowledge the statement
I voluntarily permit the client to participate in group programming services delivered by ACT Learning Centre and I acknowledge that I have read and understand the information contained in this registration package.
I understand and fully accept that there are risks involved and that accidents and injuries are possible. In case of an emergency in the absence of the caregiver, I hereby give permission to ACT Learning Centre staff to provide or pursue treatment for the client, including any necessary medical treatment.
I also hereby give permission to the staff members to disclose the information contained on this form to medical personnel. I understand that an attempt will be made to reach me by phone as soon as possible.
I acknowledge that I have read and understand the information contained in this registration package.

Name of individual who completed this form:*

First NameLast Name
Email address of the individual who completed this form:*
Today's Date:*

DayMonthYear
Please read the following:
- I consent to the collection, use, and storage of my personal information as described, and I understand how this information will be used for the purposes of this program/event.
- I understand that my participation is voluntary, and I can withdraw from the program at any time by providing written notice.
- I confirm that all information provided in this registration form is accurate to the best of my knowledge.
- I also acknowledge that I have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.
Please sign to acknowledge that you have read, understood, and agree to the terms and conditions outlined in this registration package.*

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Should be Empty:

	Select	Details
Autism
Childhood Apraxia of Speech
Intellectual Disability
Learning Disability
Anxiety
Attention Deficit Hyperactivity Disorder (ADHD)
Global Development Delay
Language Impairment
Motor Impairment
Other diagnosis
None

	Select	Details
Tonsils/Adenoids removed
Frequent Ear Infections
Head Injury
Feeding difficulties
Hearing Issues
Vision Issues
Middle Ear Tubes
Snoring
Surgery
Serious Accident or Illness
Other
None

	Select	Details
Flexible and easy going
Cheerful
Impulsive
Friendly
Playful and enjoys humour
Can be easily overwhelmed
Can be highly focused when interested in something
Prefers to play alone
Can take some time to warm up to new people or places
Special interests
Other

	Yes	No	I would like more information
Do you consent to the use of photographs including the client for the purposes of programming materials to support the client?
Do you consent the use of photographs including the client for the purposes of education, training and development of ACT staff?

	Yes	No	I would like more information
Do you consent to the use of videos including the client for the purposes of programming materials to support the client?
Do you consent the use of videos including the client for the purposes of education, training and development of ACT staff?

Registration for Resilient Minds Group

Registration for Resilient Minds Group

Client Information

Registration for Resilient Minds Group

Custody and Decision-Making

ACT's Policy for Obtaining Consent from Caregivers with Decision-Making Authority

ACT’s Policy and Procedure for Sharing Information with Caregivers with Decision-Making Authority

Registration for Resilient Minds Group

Caregiver Information

Registration for Resilient Minds Group

Medical, Social and Behavioural Information

Registration for Resilient Minds Group

Anaphylaxis Emergency Plan

Registration for Resilient Minds Group

Asthma Management Plan

Registration for Resilient Minds Group

Seizure Management Plan

Registration for Resilient Minds Group

Registration for Resilient Minds Group

Payment Policy

Registration for Resilient Minds Group

Third Party Health Insurance Policy

Registration for Resilient Minds Group

Electronic Communications Consent

Registration for Resilient Minds Group

Photo and Video Consent

Registration for Resilient Minds Group

Nut-Free Policy

Registration for Resilient Minds Group

Pick-Up and Emergency Contacts

Registration for Resilient Minds Group

Additional Information

Registration for Resilient Minds Group

Waiver of Liability and Acceptance

	Select	Details
Food(s)
Insect stings
Other