Group Program Registration

Group Program Registration

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Thank you for your interest in group programming services with ACT Learning Centre. Please complete the following registration package to begin the onboarding for our group programs. Please note that the group programs are only available in English.

If you are registering for more than one (1) child / teen, 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.

Once you have submitted your completed registration form, you will be contacted by Marnie Potter, Social Worker, MSW, RSW, within 2 business days to schedule a brief intake telephone call. This will allow Marnie to discuss more details on your selected group as well as obtain additional information on your child / teen.

If you wish to save or print a copy of your completed registration package, you will have the opportunity to do so by clicking the Print button on the last page.

If you have any questions or need assistance in completing this form, please contact ACT Learning Centre’s central 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 or toll-free at (833) 887-7529 or by email at intake@actlearningcentre.ca.

Group Program Registration

* Denotes a required field
Program Selection
Please select which group you are registering for:*

Children’s Friendship GroupTeen Neurodiversity GroupTeen 2SLGBTQIA Neurodiversity Group
Please note: Each group has criteria that the child / teen must meet to successfully participate in the programs. The eligibility of your child / teen’s acceptance into the program will be determined during the intake telephone call with Marnie Potter, Social Worker, MSW, RSW.

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.

Goals:	For children to learn skills and tools to make and keep friends and to connect with other children / teens in a safe and fun way. For caregivers to become Social Coaches for their children / teen.
Location:	106 Colonnade Road, Ottawa
When:	Every Tuesday beginning January 14, 2025 and ending April 1, 2025. Please note that there will be no sessions the week of March Break.
Time:	5:00 pm to 6:00 pm
Duration:	11 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.

Goals:	To hang out in a safe and inclusive environment, meet other neurodivergent teens, while learning social skills through engagement in activities.
Location:	106 Colonnade Road, Ottawa
When:	Every Thursday beginning January 23, 2025 and ending April 3, 2025. Please note that there will be no sessions the week of March Break.
Time:	5:00 pm to 6:00 pm
Duration:	10 week program which will be offered three (3) times annually
Ages:	13 to 17 years old
Fee:	$700.00

The Teen 2SLGBTQIA 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.

Goals:	To hang out in a safe and inclusive environment, meet other neurodivergent teens, while learning social skills through engagement in activities.
Location:	106 Colonnade Road, Ottawa
When:	Every Thursday beginning January 23, 2025 and ending April 3, 2025. Please note that there will be no sessions the week of March Break.
Time:	6:30 pm to 7:30 pm
Duration:	10 week program which will be offered three (3) times annually
Ages:	13 to 17 years old
Fee:	$700.00

Group Program Registration

* Denotes a required field
Caregiver Information
Caregiver # 1 - Full Name*

First NameLast Name
Email*
Relationship to the client*
Primary Phone*
Secondary Phone
Does Caregiver # 1 reside at the same address as the client?*

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

YesNo
Caregiver # 2 - Full Name*

First NameLast Name
Email*
Relationship to the client*
Primary Phone*
Secondary Phone
Does Caregiver # 2 reside at the same address as the client?*

YesNo
Street Address*
City*
Province*
Postal Code*

Group Program Registration

* Denotes a required field
Custody and Decision-Making Responsibility
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.

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 Caregiver # 1 and Caregiver # 2 have joint decision-making responsibilityCaregiver # 1 has sole decision-making responsibilityCaregiver # 2 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 the central 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.
By signing below, you confirm that you have read and acknowledge the Custody and Decision Making policies.*

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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.

	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)

	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	Role / Profession
Primary Healthcare Provider

	Name	Phone Number	Role / Profession
Seizure Disorder Specialist

	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

	Acknowledge
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.

	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.

Group Program Registration

* Denotes a required field
Pick up Authorization
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). 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. It is assumed that the caregivers would be the first point of contact in an emergency unless stated otherwise.
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.

Group Program Registration

* Denotes a required field
Group Program Policies and Consents
The following pages contain policies and consent forms which is part of ACT Learning Centre's onboarding process. 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.

Thank You

Group Program Registration

* Denotes a required field
Group Program Payment Policy
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.
Payment is due on the receipt of your invoice.

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.

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.
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.
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.
By signing below, you confirm that you have read and acknowledge ACT Learning Centre's Group Program Payment Policy.*

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Group Program Registration

* 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.
By signing below, you confirm that you have read and acknowledge ACT Learning Centre's Nut Free 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.

Group Program Registration

* 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

Group Program Registration

* Denotes a required field
Informed Consent, Waiver of Liability and Medical Consent

Please review the statements below and indicate that you acknowledge and provide consent by checking the box:*

	Acknowledge
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.

Please provide the full name of the individual who completed this registration form:*

First NameLast Name
Today's Date:

DayMonthYear
By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions outlined in this registration package.
- 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 below*

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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.
Thank you for taking the time to complete the registration for group programs.

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.

Marnie Potter, Social Worker, MSW, RSW, will contact you within 2 business days 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.

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 central 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 or toll-free at (833) 887-7529 or by email at intake@actlearningcentre.ca.
Should be Empty:

	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

	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

	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?

Group Program Registration

Group Program Registration

Program Selection

Group Program Registration

Client Information

Group Program Registration

Consent to Electronic Communication

Group Program Registration

Caregiver Information

Group Program Registration

Custody and Decision-Making Responsibility

Group Program Registration

Medical, Social and Behavioural Information

Group Program Registration

Asthma Management Plan

Group Program Registration

Seizure Management Plan

Group Program Registration

Anaphylaxis Emergency Plan

Group Program Registration

Pick up Authorization

Emergency Contacts

Group Program Registration

Group Program Policies and Consents

Group Program Registration

Group Program Payment Policy

Group Program Registration

Nut-Free Policy

Group Program Registration

Additional Information

Group Program Registration

Photo and Video Consent

Group Program Registration

Informed Consent, Waiver of Liability and Medical Consent

	Select	Details
Food(s)
Insect stings
Other