• Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    *Denotes required field

  • Thank you for your interest in group programs with ACT Learning Centre. Please submit one registration form per registrant.

    The form contains mandatory fields. If you receive an error message, please scroll through the page to find the missing field, indicated in red. You’ll receive an automatic email reply after successfully submitting the form. Please check your junk or spam folder if you don’t receive the email.

    The group’s lead facilitator will contact you at least three weeks before the program start date for a brief call to ensure the group is a good fit for your child or teen. The group programs are currently available in English.

    If you’d like help completing the form or would like more information, please contact the client services department at intake@actlearningcentre.ca, or by phone at (343) 887-2287 ext. 0 (local) or (833) 887-7529 ext. 0 (toll-free).

  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Program Selection

  • Please select which group you are registering for:*
  • Please select the session of the Children's Friendship Group you are registering for:*
  • Please select the session of the Teen Neurodiversity Group you are registering for:*
  • Please select the session of the Resilient Minds Group you are registering for:*
  • Please select the session of the Kaleidoscope Crew you are registering for:*

  • The Children’s Friendship Group helps neurodiverse elementary school aged children (with or without a diagnosis of ADHD or autism) who have trouble making or keeping friends through skill-building group sessions. The group will meet once a week, with the caregivers in one group and children in the other.

    What to expect: A fun and welcoming environment for children to learn skills to meet and make friends.
    An evidence-based, skill-building group for children.
    Weekly caregivers’ group (held at the same time as the children’s group) to get the tools and knowledge to become social coaches for your children.
    Location: 106 Colonnade Road, Ottawa
     
    When: Every Tuesday 
    Time: 5:00 pm to 6:00 pm
    Duration: 10 weeks
    Ages: 9 to 12 years old
    Fee: $1,000.00

  • The Teen Neurodiversity Group is an informal group for autistic and neurodiverse teens to gather, hang out, and have fun in a safe and welcoming environment. The teens will work with facilitators to decide what activities they would like to do such as crafts, video game night, board games, excursion to McDonald's or Tim Hortons, hanging out at the Arboretum or Experimental Farm, poutine night etc. This program usually includes 2 to 3 low cost outings.

    What to expect: Soft coaching around social skills, group rules, boundaries, consent etc.
    Teens collaborate with group facilitators to choose activities they want to participate in.
    Crafts, video game night, board games, low-cost outings etc.
    Location: 106 Colonnade Road, Ottawa
     
    When: Every Thursday
    Time: 5:00 pm to 6:00 pm
    Duration: 10 weeks
    Ages: 13 to 17 years old
    Fee: $700.00

  • Resilient Minds is designed to offer a group program to help children build upon emotional awareness and self-regulation skills through a combination of psychoeducation discussions, sensory exploration, mindfulness, and creative activities.  Please note that this group is only available in English.

    Location: 106 Colonnade Road, Ottawa
     
    When: Every Thursday 
    Time: 5:00 pm to 6:30 pm
    Duration: 6 weeks
    Ages: 7 to 9 years old
    Fee: $900.00

  • The Kaleidoscope Crew: 2SLGBTQIA+ Group is designed to offer a supportive, affirming space for young people to explore identity, community and mental well-being.

    Grounded in a Narrative Therapy approach, teens will learn to connect with a broader community and shared history while developing resilience, self-advocacy and confidence

    Location: 106 Colonnade Road, Ottawa
     
    When: Every Wednesday
    Time: 5:00 pm to 6:30 pm
    Duration: 8 weeks
    Ages: 13 to 17 years old
    Fee: $465.00
  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Client Information

  • Client's Date of Birth*
     - -
  • Has the client been registered for or had any services with ACT Learning Centre in the past?*
  • Has any of your information (Client address, email, phone number or Caregiver address, email or phone number)changed since your last registration?*
  • Whose information has changed?*
  • Would you like to add an email address for the client (the child or youth) so that ACT Learning Centre can share any communications regarding the group program(s) with the client?*
  • Client's Gender Identity*
  • Client's Pronouns*
  • Client's Primary Language*
  • Does the client wish to identify as Indigenous?*
  • Does the client have any mobility or accessibility concerns?*
  • Is the client motivated to attend and participate in a group program?*
  • Is the client able to have basic back and forth reciprocal communication?*
  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * 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:*
  • Do you have your legal documentation on hand readily available to upload and confirm the sole decision-making status?*

  • Please ensure to provide this documentation at your earliest opportunity. You can email your documents to ACT's Intake Department at intake@actlearningcentre.ca.

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  • Are there any disputes between the caregivers regarding decision making?*

  • 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.

  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Caregiver Information

  • Caregiver 1

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Does Caregiver 1 reside at the same address as the client?*
  • Would you like to add another caregiver?*

  • You have selected joint 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 Caregiver 2 below.

  • Caregiver 2

  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Does Caregiver 2 live at the same address as Caregiver 1?*
  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Medical, Social and Behavioural Information

  • Does the client have an anaphylactic allergy? If the answer is yes, you will be required to complete the Anaphylaxis Emergency Plan.*
  • Does the client have other non-anaphylactic allergies? If the answer is yes, please provide details below.*
  • Does the client have asthma? If the answer is yes, you will be required to complete the Asthma Management Plan on the following pages.*
  • Does the client have seizures? If the answer is yes, you will be required to complete the Seizure Management Plan on the following pages.*
  • Does the client have any medical conditions, for example, diabetes, hemophilia, etc. that could require intervention on site?*
  • Does the client take any medications for medical conditions?*
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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Anaphylaxis Emergency Plan

  • Understanding that health and medical needs may change over time, it’s important to review your plan of care every year.  If you need to make a change to your anaphylaxis emergency plan of care, please contact ACT Learning Centre's Client Services Department by email at intake@actlearningcentre.ca or by calling (343) 887-2287.

  • The following individual, *   *   has a potentially life-threatening (anaphylactic) allergy to:

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  • Expiry Date of the Epinephrine Auto-Injector*
     - -
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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Asthma Management Plan

  • Understanding that health and medical needs may change over time, it’s important to review your plan of care every year.  If you need to make a change to your asthma management plan of care, please contact ACT Learning Centre's Client Services Department by email at intake@actlearningcentre.ca or by calling (343) 887-2287.

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  • Does the client use a reliever inhaler (fast-acting, usually blue)?*
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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Seizure Management Plan

  • Understanding that health and medical needs may change over time, it’s important to review your plan of care every year.  If you need to make a change to your seizure management plan of care, please contact ACT Learning Centre's Client Services Department by email at intake@actlearningcentre.ca or by calling (343) 887-2287.

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  • Epilepsy/Seizure Disorder Specialist Information*
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  • Do you authorize ACT Learning Centre to contact the above health care provider as required to attend to the well-being of the client?*
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  • Please select the type of seizure(s) the client has:*
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  • Has a routine or rescue medication been prescribed to the child / teen?*
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  • Do you authorize the child / teen to carry the required medication at all times?*
  • Do you authorize ACT Learning Centre to store the required medication securely so that it can be accessed by ACT staff for the client as required?*
  • The medication is kept in my child / teen's:*

  • Caregiver(s) Authorization to Administer Prescribed Medication

    The administration of medication involves certain elements of risk, including, but not limited to illness, adverse reactions or other complications. Reactions caused by the administration of any medication can occur without fault on any party, including the child / teen, or ACT Learning Centre or its employees or agents. By requesting and consenting to the administration of medication by an employee of ACT, or by authorizing the self-administration of medication by the child / teen, you are assuming any associated risks.

    In life-threatening emergencies, staff will administer prescribed medication to the child / teen “in loco parentis”, not as healthcare professionals.

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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • 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 Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • 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,   *   * , understand that by signing this form, I am committing that the client,   *   *   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.

  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • 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)
  • 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.*
  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Electronic Communications Consent

  • ACT Learning Centre uses reasonable means to protect the security and privacy of information sent and received by email. However, email communication always includes some risk which may include:

    • Emails can be circulated, sent to others, and stored on paper or on a computer.
    • It is easy to send an email to the wrong person.
    • Copies of emails may exist even after the sender or receiver has deleted his or her copy.
    • Email transmission is not secure and can be stolen, emailed to others and viewed without warning.
    • Emails can be used to introduce viruses into computer systems.
    • Emails can be used as evidence in court.
  • Please select your preferred method of communication. Communications may include general communications as well as site specific communications such as emergency closures.*
  • Do you understand the risks of email transmission/correspondence?*
  • Do you consent to having your reports and/or relevant clinical information sent to you by email? Clinical information would always be sent as a password protected document.*
  • Do you consent to receiving electronic communications, including newsletters and messages about new groups, programs and services offered by ACT Learning Centre? You can withdraw your consent and unsubscribe at any time.
  • Please indicate which caregiver is to receive communications from ACT Learning Centre:*

  • SMS (text) Messages

    ACT Learning Centre uses email and telephone as our primary method of communication. In situations where staff at ACT have attempted to contact you numerous times with no success, or if the matter is time sensitive, ACT staff may resort to SMS (text) messaging. Text and data rates may apply.  The frequency of SMS messages received will vary depending on the reason ACT is contacting you. You can opt-out anytime from receiving SMS messages by replying STOP. To review ACT Learning Centre's Privacy Policy, please click on the following link:  https://actlearningcentre.ca/privacy-policy/  

  • Do you provide consent to receiving SMS messages from ACT Learning Centre?*
  • Do you consent to sharing your child or teen's contact information (telephone number and/or email) to be shared with other individuals participating in the same group program for extra-curricular activities outside of group programming? Consent is completely optional.*
  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • Photo and Video Consent

  • Photos and/or videos of clients may be used by the ACT Learning Centre team with your consent. The client's image/video will not be used in any circumstances outside of the approved circumstances below. Please indicate whether you consent to photos and/or videos by making a selection in each box below.

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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * 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.

  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • 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:*
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  • 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?*
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  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * Denotes a required field

  • 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 Marnie Potter, Social Worker, MSW, RSW 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) 343-571-8450
    Email:  mpotter@actlearningcentre.ca

  • Registration for Children and Teen Group Programs

    Registration for Children and Teen Group Programs

    * 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.

    You will also be contacted by Marnie Potter, Social Worker, MSW, RSW, to schedule a brief intake telephone call to discuss more details on your selected group as well as obtain additional information on your child / teen.

    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.

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  • Today's Date:*
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  • 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.
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