Client & Customer
Registration & Intake Form

Please carefully read and fill out the form to the best of your ability. This will help us better serve you and your needs. Please carefully read our commitment to our clients and customers at the bottom of this page.
Email *
Name *
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Phone number *
Address *
Emergency Contact (Name, Phone, E-Mail) *
How do you identify? *
Date of birth *
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Please select the service you are registering for *
1 - Do you believe that you have experienced a traumatic incident or traumatic incidents? (Please select the answer that applies to you - See description below before you answer) *
What can be understood as a perceived traumatic incident?
Contributing factors - Traumatic incidents (Trauma) - What qualifies as trauma:
Traumatic events may include any or all of the following as well as other events not listed[1]:
  • Harassment/bullying, Sexual assault, Abuse and Rape
  • Crime victims
  • Child abuse (physical, sexual, neglect, emotional maltreatment, bullying, or other forms of abuse)
  • Family break-up (divorce, substance abuse, career travel)
  • Combat trauma (civilian & non-civilian)
  • Domestic or intimate partner violence
  • Industrial accident victims
  • Occupational trauma (military [civilian, reg & res, land, air, marine], police, fire, EMS, nurse, physician, psychologists, clergy, railroad, etc.)
  • Torture & confinement camps (i.e., Holocaust, Refuge)
  • Accident victims (MVA, workplace, transport, sporting, etc.)
  • Physical ailment, injury, surgery (cancer, amputee, diabetes, etc.)
  • Natural disasters (tornados, earthquake, hurricanes, forest fires)
  • Pandemic (loss of life and sense of agency/control)
  • People who learn of the sudden death of a close friend or relative (this can include death by suicide)
  • Exposure to animal abuse
  • Acts of terrorism
  • Secondary exposure to all of the above (witnesses and discussions/investigations).
[1] Group Approaches with Trauma Survivors TI-105 Manual – Traumatology Institute
2 - If you answered yes to question 1 (Please select the answer that applies to you - See description of the impact of trauma below before you answer) *
The Impact of Trauma
“The impact of exposure to a traumatic incident can change a life in dramatic and unexpected ways. Post-Traumatic Stress Disorder (PTSD) is a syndrome that occurs in some persons following a major stressor. It is made up of a cluster of symptoms that can lead to a serious deterioration in everyday functioning. If you have not been able to resolve a stressful event you may be suffering from the ongoing repercussions of trauma.”

Exposure to a traumatic incident can have a profound impact on a person's life, emotionally, psychologically, and physically. It can lead to the development of Post-Traumatic Stress Disorder (PTSD), which is a serious mental health condition that can interfere with daily functioning. It is important to note that there is also a term called Acute Stress Disorder (ASD). Which can often show signs and symptoms that are similar to those of PTSD. However, ASD is historically categorized immediately after, up to four weeks following an incident. PTSD can be a continuation of ASD, or it may manifest up to 6 months after the incident and can last up to one month.

Signs to look out for
Notably, PTSD can affect someone in a way they may not always associate with the traumatic incident. Here are a few things we can watch out for and focus attention to that could all point to ASD/PTSD:
  • Physiological reactivity
  • Nightmares
  • Increased feelings of nervousness
  • Anxiety
  • Loss of interest in things that once felt fulfilling
  • “Jumpiness”
  • Loss of hope
  • Outbursts of temper and constant feelings of being in harm’s way
Navigating the Trauma landscape can be complex, and this is an area that if the appropriate level of attention and care is applied, many can move forward with confidence.
3 - If you answered yes to question 1, have you or are you currently seeing a trauma informed professional or para-professional? (Please select the answer that applies to you) *
Were you referred to us by a trauma informed professional or para-professional? *
4 - Do you believe that you have been physically bullied? (Please select the answer that applies to you - See description below question 5 before you answer) *
5 - Do you believe that you have been psychologically bullied? (Please select the answer that applies to you - See description below before you answer) *
What is bullying?
Bullying is the repetitive, intentional hurting of one person or group by another person or group, where the relationship involves an imbalance of power.
6 - Do you believe that you have been bullied on-line? (Please select the answer that applies to you - See description below before you answer) *
What is cyberbullying?
Cyberbullying involves the use of technology to harass, threaten, or embarrass others. This can include:
  • Online harassment: Sending abusive or threatening messages
  • Posting embarrassing or private information: NO consent to share
  • Creating fake profiles: Pretending to be someone else to harm another person
  • Exclusion: Intentionally excluding someone from online groups or activities
7 - Has a doctor, or any other medical professional informed you that you should avoid physical activity? *
If you answered yes to the above noted question (7), what are the limitations? *
8 - Are you taking any medications that can interfere with physical activity, or interfere with communications between members of our team and/or other learners/students? (This includes prescription and non-prescription meds) *
Our commitment to you (See description below before you answer). *
Our commitment - Your safety and wellbeing
Our organization is deeply committed to the privacy, safety, well-being, and professional growth of our clients and customers. We prioritize physical and mental health, recognizing that these factors are essential for optimal performance and satisfaction. We strive to create a supportive and inclusive environment where individuals feel valued, respected, and empowered to reach their full potential.

Your privacy, safety, and well-being are paramount to us. We are dedicated to providing an environment where you can feel comfortable and secure. We adhere to a rigorous code of ethics, guided by our certifying organizations, to ensure that all our actions are aligned with the highest standards of professionalism. We are committed to providing opportunities for learning and growth, while always prioritizing your well-being. Please know that we will and are committed to doing everything reasonably possible to do NO harm while understanding the individual and unique challenges our clients and customers navigate. We expect the same respect from our clients during all interactions, including consultations, training sessions, and group sessions.
Please note: Your privacy and the protection of your personal information are paramount. This information is not shared with anyone, and our practices strictly adhere to all applicable laws and regulations related to mental health care and data privacy in Canada. Also ensure to fill out and sign the liability waiver for on our registration and intake page (click here). 
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