Free To Be Group Application - Family Services York Region

About You:

Name*

First Last

Date of Birth*

Address*

Street Address City Province Postal Code

Phone*

Okay to leave a message?*

Yes

No

Email*

Enter Email Confirm Email

(example@example.com)

Gender*

Pronouns*

Racial Identity*

(Examples: Black, South East Asian, White)

Ethnicity*

(Examples: Canadian, African, Iranian)

How long have you lived in Canada?*

Your Emergency Contact Information:

Name*

Phone*

Relation to You?*

More About You:

Are you currently / or have been involved with Children's Aid Society (CAS)?*

Yes

No

Total Household Income $*

(Examples: $ Gross Income Per Year, Employment Insurance, Prefer Not to Disclose)

How did you hear about our group?*

What would you like to experience as a participant of the group? What are some topics of interest or questions you would like to explore?*

Consent to Services:

Consent*

Yes, I have read and understood the terms of confidentiality and voluntarily consent to group counselling at Family Services York Region as outlined below.

CLIENT CONFIDENTIALITY
Information is collected and records are kept for anyone seeking and accessing services at FSYR. Your information is kept strictly confidential within the agency, except in the following circumstances:
• Concern that a child under 16 years is at risk of abuse or neglect
• Imminent risk of physical harm to oneself
• Direct threat of physical harm to another person
• When records are subpoenaed by a court of law or the agency is presented with a search warrant
• When a client discloses that they were sexually abused by a regulated health professional

Additional information about privacy, confidentiality and records can be found on our website (fsyr.thedev.ca).

CONSENT TO CONDITIONS OF SERVICE
FSYR is an inclusive, diverse organization that upholds the right for everyone to be treated with dignity, respect and without discrimination. We believe in the importance of a safe and secure environment to promote the fullest development of individuals, couples and families.

At all times, you have the right to make decisions about your service and participation, including to not discuss a topic, to terminate the session and/or counselling. Counsellors are responsible for explaining the foreseeable risks and benefits associated with withdrawing or withholding consent. You also have the right to bring forward any questions, concerns or complaints to the group facilitator or their supervisor to work towards a resolution.

VIRTUAL SERVICES
Many people prefer virtual services as it offers the benefits of accessibility, convenience and flexibility that may not be available when accessing counselling in person. FSYR utilizes virtual end-to-end encrypted platforms that comply with all Canadian privacy legislation. We make every effort to monitor and maintain privacy and confidentiality, including password protection of confidential information and providing counselling in private spaces. With technology however, there is always some risk of confidential and private information being accessed by unauthorized parties. You have the right to refuse counselling services virtually and discuss alternate services. You also have the right to withdraw consent at any time.

Signature*

Date*

Date Application Signed and Completed

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