Thank you for your interest in ACT Learning Centre's Sleep Consultation Program. Please complete the following registration package to begin the onboarding for services.  If you are registering for more than one (1) individual, 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.

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.

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.

Primary Caregiver

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.

Payment is due on the receipt of your invoice.

Fees for Sleep Consultation services 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 for Registered Behaviour Analyst and whether the fees are eligible.

Virtual services and report writing will be billed at the rate of $145.00 per hour.

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.

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.

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.

Please check the box below to confirm that you have read and agree with the information provided above.

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)

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.

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/  

ACT Learning Centre takes the health and well-being of our clients and staff very seriously. We would like to take this opportunity to remind all clients receiving services at ACT of our Late Arrival, Cancellation and Illness Policy. These policies and guidelines are put in place to ensure that everyone can be kept as healthy as possible. If the client is not feeling well, please do not come to the centre. Thank you for your continued support and cooperation.

We require 24 hours notice for the cancellation of a scheduled appointment. Please contact our Intake Department to notify us of a cancellation by calling (343) 887-2287 (local) or (833) 887-7529 (toll-free) or by email at intake@actlearningcentre.ca.

If we do not receive a minimum of 24 hours' notice for cancellations, you will be charged for 50% of the scheduled therapy hours.

Clients are billed for their scheduled session time. In the event that a client is late to their session, they will be billed based on their scheduled start time, not their arrival time. In most cases, additional time cannot be added onto the end of the session to make up for late arrivals.

If a scheduled re-occurring session falls on a statutory holiday, you will not be charged for that session.

Thank you for taking the time to complete the registration for Sleep Consultation services. 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's Intake Department 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 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.