Name *

First Name

Last Name

Name *

First Name

Last Name

Phone

(###)

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Preferred Method of Contact: *

Phone

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have: *

Primary Care & Control

Partial Custody

Supervised Visits

Doctor's Name *

First Name

Last Name

Doctor's Phone *

(###)

###

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Have you or any of your children been given a mental health diagnosis from a mental health professional? *

Yes

No

Do you or any of your children have problems with substance use? *

Yes

No

Do you use mind/mood altering substances? *

Yes

No

Do you agree to remain sober (abstain from any non medically prescribed substance use?) for the duration of the 8 week of program? *

Yes

No

Are you and/or your child interested in counseling? *

Yes

No

I understand that in order to qualify for parent / child counselling: *

Please choose every option to show your understanding.

I must be at least 6 months sober

I must have biological parents consent for therapy if I don’t have primary care and control custody

I must be interviewed and approved by the program director to determine if counselling is a good fit at this time

Emergency Contact: *

First Name

Last Name

Home Phone: *

(###)

###

####

Cell Phone: *

(###)

###

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Work Phone: *

(###)

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I give my permission for Marie Thiessen, Caleb Thiessen or any other DWCC staff to contact this person in the event of an emergency with myself or one of my children *

Yes, I give my permission

No, I do not give my permission

Please agree with the following: *

I understand that Healthy Parent Healthy Home is a group-based attachment parenting program that involves sharing personal struggles and victories. I understand that the group follows the rules of respecting what is shared in our group stays within the group. However I also understand that if any DWCC staff helping with the program suspects myself or my children are being abused or are going to harm themselves, that the DWCC staff is required to report abuse / break this confidentiality in order to keep me and my children safe and healthy.

I understand that Healthy Parent Healthy Home and DWCC are not crisis centres and if at any point the director feels this is not the best timing to complete the program due to crisis, I may be asked to resign from the program and try to complete it at another time that is better. I understand the director or other staff may help me with this transition to find other resources that may be more appropriate for my stage of growth / recovery.

I confirm that the information given above is correct to the best of my ability:

I understand that this program is free of charge but I will treat it just as seriously as a paid program

I Confirm that if I am accepted to the program I will do my absolute best to attend all 8 sessions, engage in the homework, agree to the in-home visit and group activity, and grow my relationship with myself and my child (ren).