Family Support Group Registration - December 17, 2019

Topic: Self care and coping with the holidays

Family support groups are held on the third Tuesday of each month from 6 to 7:30 pm in conference room 1425 at The Royal, 1145 Carling Avenue or via telemedicine at the Pembroke Civic Complex, 425 Cecelia Street, Pembroke.

Question Title

* 1. Will you be attending in Ottawa or Pembroke?

Royal Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa

Pembroke Civic Complex, 425 Cecelia Street, Pembroke (via telemedicine)

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* 2. What is your relationship to the primary person you are supporting? Please choose one response that BEST applies to your situation

I am here for myself

I am a spouse/partner

I am a parent

I am a child

I am a sibling

I am an extended family member

I am a friend

I am a health care provider

I am a peer supporter

I am a student

Other (please specify)

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* 3. How many years have you been a caregiver for the primary person you are supporting?

Less than one year

One year

2 to 5 years

6 to 10 years

11 to 15 years

16 to 20 years

21 years and over

Supporting self

Not applicable

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* 4. What is the age of the person you are supporting?

17 years or under

18 - 25 years

26 - 35 years

36 - 40 years

41 - 50 years

51 - 64 years

Not applicable

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* 5. What community are you from?

Ottawa

Gatineau / Outaouais

Lanark County

Brockville, Leeds and Grenville

Cornwall, Stormont and Dundas

Prescott Russell

Renfrew County

Other (please specify)

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* 6. How did you learn about this event (please specify source)?

Email (i.e., a friend, colleague, provider)

Website (i.e., The Royal, Ottawa 211)

Social media (i.e., Twitter, Facebook, LinkedIn)

Flyer (i.e., The Royal, Ottawa Hospital, other)

Healthcare provider (i.e., physician, social worker)

Word of mouth (i.e., friend, family, social work)

Other (please specify)

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* 7. To be added to our distribution list, please provide us with your email address (ensure accuracy)

Name

Email Address