South Asian Women’s Group Application HomeSouth Asian Women’s Group Application South Asian Women’s Group Application "*" indicates required fields Name* First Last Date of Birth* Month Day Year Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*Okay to leave a message?* Yes No Email* example@example.comGender* How long have you lived in Canada?* Language of Preference?* Total Household Income $ (Gross per Year):$0 – $40,000$40,000 – $80,000$80,000 – $120,000 or moreSelect income rangeAre you currently / or have been involved with Children's Aid Society (CAS)?* Yes No How did you hear about our women's groups?* Current Group Member Presentation Faith Group Friends School Family Doctor Other Emergency Contact Information:Name* Phone*Relation to You?* Client 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 (www.fsyr.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* Month Day Year Date Application Signed and CompletedCAPTCHA 9409Δ