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123 Street Avenue, City Town, 99999

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Link to read me page with more information.

Mindfulness Registration

Register for our programs covered by Alberta Health Care here

"Mindfulness with Animals" Registration Form

Thank you for your interest in our 3 hr Mindfulness with Animals Workshop

Criteria for Alberta Health Care Coverage:

•  Stress or stress-related issues
•  Loss, life changes, challenges with work or relationships
•  Depression, Anxiety, Seasonal Affective Disorder
•  Medical Condition or Health Issues (e.g. chronic illness, pain,…)

Please note this program is not appropriate for those experiencing:

  • Active Substance abuse/dependency (current or within last 12 months)
  • Mental Health Disorder that is significantly impairing daily functioning
  • Severe Anxiety, Depression or other Mental Illness
  • Suicidal Ideation or Psychosis
  • Borderline Personality Disorder

Note: I am offering all therapy services as a physician under my medical license. The information gathered on this form is necessary to provide optimal services to you; meet the medical charting requirements of the Alberta College of Physicians & Surgeons; and to verify that the eligibility criteria are met for Alberta Health Care Insurance Plan (AHCIP) coverage. Since an individual intake session is not required for participation in the small group programs, this registration form is quite comprehensive. All information provided is confidential as per the Health Information Act (HIA) of Alberta. Thank you.

**Cancellation Policy
3 business days notice is required for cancelling 

*N.B.: I can not bill Alberta Health Care if we do not have an in-person session 

**Cancellation Fees**
Group Sessions/Workshops: $20/hr
3 hr       $60
4 hr       $80
 

MINDFULNESS WITH ANIMALS REGISTRATION FORM

 
Please choose a workshop *
Limited to 4 participants per group.
Name *
Name
Birthday *
Birthday
** Please bring your AHCIP Card to your intake session** (Enter 9 digit number without spaces)
Address *
Address
Phone (Home) *
Phone (Home)
Phone (Cell) *
Phone (Cell)
Include name and location
Are you under the care of a Mental Health Professional? *
If yes, please provide details below
Provide name, credentials (Psychiatrist/Psychologist/Other) and location. Also include how long you have been under their care and frequency of appointments
Please list any medications including dose and frequency
Please list and indicate if you have ever experienced an anaphylactic reaction. (If so please bring Epi-pen)
Please list any significant health issues other than cancer (e.g. asthma, heart condition, diabetes. etc.)
1 (significant impairment/disability) → 10 (optimal)
Mental Health *
Have you ever been DIAGNOSED with (check all that apply):
Please list (e.g. depression, anxiety, insomnia, etc.)
1 (significant impairment/disability) → 10 (optimal)
1 (none/minimal) → 5 (moderate) → 10 (overwhelming)
1 (significant impairment/disability) → 10 (optimal)
e.g. Mindfulness, Meditation, Experiential Therapy, Time in Nature, etc.
Briefly describe your experience with horses, including any significant events.
Comfort Level with Horses *
If from a doctor or other healthcare provider please include name
Emergency Contact Information
Full Name & Relationship to Registrant
Emergency Contact (Home Phone) *
Emergency Contact (Home Phone)
Emergency Contact (Cell Phone)
Emergency Contact (Cell Phone)

Thank you! I will be in touch with you shortly with more details.