Empower Parents

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

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)

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}