Family Service Toronto Adult Caregiver Peer Support Group Registration Form

*Please note that all participants (including those from the same household) are required to register individually.

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* 1. What is your name?

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* 2. What is your home address? (Required for demographic purposes)

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* 3. What is your birthday? (Required for demographic purposes)

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* 4. What is your phone number?

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* 5. Can we leave a message at this number?

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* 6. What is your email address? Please write ‘N/A’ if you do not use email.

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* 7. What is your preferred method of contact? (Please check one)

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* 8. What is your relationship to the person you’re a caregiver for?

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* 9. What is the age of the person you provide care for?

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* 10. Where does the person who you provide care for live?

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* 11. Why are you interested in this group? (Check all that apply)

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* 12. Will you be joining the group via video conference (Zoom) or by phone?

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* 13. What do you hope to get out of participating in this group?

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* 14. What specific topics would you like to discuss?

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* 15. Are you interested in finding out more about a paid peer facilitator role?

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* 16. Are you interested in participating in professionally led educational sessions (separate from this group)?

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* 17. If you responded ‘yes’ to question 16, what topics would you be interested in learning about?

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* 18. Is there anything that is important for us to know to help you successfully participate in this group?

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* 19. By checking this box, I am consenting to receive service from FST and to the collection of my personal information. I understand that non-identifying information will be shared with the funder of this project.

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* 20. By checking this box, I consent to participating in the peer support group facilitated by Family Service Toronto using Zoom. I understand that while there are security measures in place to reduce risk, any internet-based communication cannot be 100% guaranteed to be secure/ confidential.

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* 21. By checking this box, I confirm that I understand that Family Service Toronto is required by law to disclose information about me without my consent if :

Someone is in danger of immediate harm

FST staff suspect or know a child under 16 is at risk or has been abused or neglected

Abuse of an individual with a developmental disability is witnessed, suspected, or alleged

FST is served with a court order, subpoena, or warrant, or required by law

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