Empower Parents

{workshopTitle}

Hosted by Julia Ryan Psychology

{workshopTitle} {workshopDescription}

Instructors
- {clinicianNames}
Details
- Session Dates:
  - Session 1: {session1DateToString} ({session1StartTime:input_70_timeInput} to {session1EndTime:input_98_timeInput})
  - Session 2: {session2DateToString} ({session2StartTime:input_72_timeInput} to {session2EndTime:input_97_timeInput})
- Registration Deadline: {registrationDeadlineDate}
- Location:
  Julia Ryan Psychology
  111 Sherwood Drive
  Ottawa, ON
  K1Y 3V1
- Parking: Free on-site parking and nearby street parking are available
Fees

One caregiver
- Total Price: ${price1PplTotal}
- Payment Schedule: ${price1PplDeposit} deposit + ${price1PplBalance} final payment.
Two caregivers
- Total Price: ${price2PplTotal}
- Second caregiver discount: We offer a reduced rate for the second caregiver attending the workshop.
- Payment Schedule: ${price2PplDeposit} deposit + ${price2PplBalance} final payment.
Insurance Reimbursement

This workshop consists of two 6-hour sessions. Your receipts will be itemized per session:

Receipts for one Caregiver:
- One receipt for ${price1PplBlock} per 6-hour session.
Receipts for two Caregivers:
- Caregiver 1: One receipt for ${price1PplBlock} per 6-hour session.
- Caregiver 2: One receipt for ${price2PplBlock} per 6-hour session.
Contact us

For any questions, please contact julia@drjuliaryan.ca
Parameter Fields - [P]

Fields to be pre-filled using a Jotform Prefill Table:

Steps: "Empower Parents" Form > Publish > Prefill > Tables Prefill > Add new prefill

Instead of manually typing workshop details (like the date or price) directly into the form for every variant of a workshop, these fields act as placeholders. When the form is used, these placeholders are automatically filled in with the correct information from your prefill table.
[P] Workshop Description
[P] Workshop title
E.g. "Empower Parents: Young adults (16+)"
[P] Clinician Names
E.g. "Dr. Julia Ryan and Dr. Kelly Weegar"
[P] Workshop description
[P] Prices
[P] Price 1 ppl deposit
Deposit price for one caregiver
[P] Price 1 ppl balance
Remaining balance for one caregiver after deposit (Deposit + Balance = Total price)
[P] Price 2 ppl deposit
Deposit price for two caregivers
[P] Price 2 ppl balance
Remaining balance for two caregivers after deposit (Deposit + Balance = Total price)
[P] Dates & Times
[P] Session 1 date

YearMonthDay
Date
[P] Session 1 start time

Hour Minutes

AM/PM Option
[P] Session 1 end time

Hour Minutes

AM/PM Option
[P] Session 2 date

YearMonthDay
Date
[P] Session 2 start time

Hour Minutes

AM/PM Option
[P] Session 2 end time

Hour Minutes

AM/PM Option
[P] Direct Billing
[P] Is this group service covered by insurance?

YesNo
Hidden Fields - [H]

Used for calculations & conditional logic
[H] Number of caregivers attending
[H] Dates
[H] Session 1 date to string
[H] Session 2 date to string
[H] Registration deadline date
Subtracts 14 days from Session 1 date; returns a string.
[H] Registration deadline date to string
[H] Prices
[H] Price 1 ppl total
[H] Price 2 ppl total
[H] Price 1st caregiver per session for insurance
[H] Price 2nd caregiver per session for insurance
[H] Direct Billing & eCommerce
[H] Direct billing requested?

YesNo
[H] Telus eClaims form status

Emailed to registrantAlready on fileNot requested
[H] Price adjuster for testing
[H] Stripe price-setter
User input fields

Keep this Paragraph element hidden
Your name*

First NameLast Name
Your email*
example@example.com
Your phone
Please enter a valid phone number.
How many caregivers are you registering for the workshop?*

One caregiver (myself)Two caregivers (e.g. myself and my spouse)
Second caregiver's name*

First NameLast Name
Second caregiver's email*
example@example.com
Second caregiver's phone
Please enter a valid phone number.

Background information
Tell us a bit about what you hope to gain from this group
Examples: more ways to connect with my child, coping strategies for myself, tools for better communication, connecting with other caregivers, a supportive community, etc.
How did you hear about our services?

Friend, family or colleagueOur newsletterSocial mediaGoogle, Bing, etc.Referral from one of our clientsReferral from a mental health professionalOther
If you're comfortable sharing, who was the mental health professional that referred you to us?
Mental health professional's name
We send regular newsletters with updates about our services and other community resources. Filling out our forms adds you to our list automatically. If you do not wish to receive our newsletter, you can opt out below

I don't want to receive the newsletter

Consent for Registration

Please review the following terms and conditions
Name of Signatory*

First NameLast Name
Signature*

Clear
Date Signed*

DayMonthYear
Day-Month-Year

Direct Billing to Insurance
We offer direct billing to most major insurance companies, where we bill your insurer directly so you only pay the portion not covered. To set up direct billing, please answer below:*

Yes, I'd like to set up direct billingNo, I don't want to set up direct billingNo, I've already set up direct billing with Julia Ryan Psychology
Would you like us to bill your insurance company for this workshop?*

YesNo
We'll email the direct billing form once you're registered for the workshop
Final Step: Reserve Your Spot at {workshopTitle}

Reserve your spot(s) by making a deposit.

The deposit will be deducted from your total workshop fees.

Workshop ticket(s)*

CADPrice to reserve your seat(s)

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing email*
Your deposit receipt will be emailed to this address
Billing Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Final Payment Details

Your remaining balance of ${price1PplBalance} is payable by credit card or e-transfer at the start of the first session.

To simplify your insurance claims process, we'll email you a receipt for half of the total amount by email after each of the two sessions.
Final Payment Details

Your remaining balance of ${price2PplBalance} for two caregivers is payable by credit card or e-transfer at the start of the first session.

To simplify your insurance claims process, we'll email you a receipt for half of the total amount by email after each of the two sessions.
Please tick the box before registering for the workshop*
Should be Empty:

{workshopTitle}

Hosted by Julia Ryan Psychology

Instructors

Details

Fees

Insurance Reimbursement

Contact us

Parameter Fields - [P]

[P] Workshop Description

[P] Prices

[P] Dates & Times

[P] Direct Billing

Hidden Fields - [H]

[H] Dates

[H] Prices

[H] Direct Billing & eCommerce

User input fields

Background information

Consent for Registration

Direct Billing to Insurance

We'll email the direct billing form once you're registered for the workshop

Final Step: Reserve Your Spot at {workshopTitle}

Final Payment Details

Final Payment Details