I, and my children are applying for the 8 week healthy Parent Healthy Home program for the following reasons:
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Name
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First Name
Last Name
Age
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Grade
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Favourite Hobbies
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Other important things to know about my child:
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Name
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First Name
Last Name
Email
Phone
(###)
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Preferred Method of Contact:
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have:
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Are both parents actively involved in the child's life? Please describe how. Are there any other adults in a parental role? (step-parents/partners)
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Doctor's Name
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First Name
Last Name
Doctor's Location
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Doctor's Phone
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(###)
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Current Medications for you and your children:
Do you or your children have any allergies? Or Food Allergies?
Please list down below
Have you or any of your children been given a mental health diagnosis from a mental health professional?
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If yes, please list diagnosis:
Do you or any of your children have problems with substance use?
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If yes, are you currently sober? How long have you been sober?
Do you use mind/mood altering substances?
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If yes, when was the last time you used?
Do you agree to remain sober (abstain from any non medically prescribed substance use?) for the duration of the 8 week of program?
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Are you and/or your child interested in counseling?
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if yes, state briefly in your own words why you, and / or your children are interested in counselling:
I understand that in order to qualify for parent / child counselling:
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Please choose every option to show your understanding.
Emergency Contact:
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First Name
Last Name
Relationship:
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Home Phone:
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(###)
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Cell Phone:
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(###)
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Work Phone:
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(###)
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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
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Please agree with the following:
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