Personal Informations
First Name
Last Name
Email
Phone
Format: xxxxxxxxxx
Date of Birth
YYYY-MM-DD
Address
City
Province
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Quebec
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Saskatchewan
Yukon
Postal Code
Country
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Canada
United States
Other
Language
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French
English
What mental health issue(s) do you live with?
Anxiety
Depression
Bipolarity
Request help for a relative
Other-s
Prefer not to answer
Specify if desired
Gender identity
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Male
Female
Nonbinary
Other (specify if desired)
Prefer not to answer
Please specify your gender identity
How did you hear about Relief's self-management workshops?
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Partenaire de Relief
Registration
Indicate which organization refers you and pays the cost of the workshop for you.
I confirm that I have received authorization from this organization to register for the workshop.
I agree that Relief may share my information with CIUSSS de l'Est-de-l'Île-de-Montréal.
Please select the theme of your workshop.
Please select...
Living with anxiety
Living with depression
Living with bipolarity
Living with a better self-esteem
Living with a better workplace balance
Vivre avec l’anxiété (French)
Vivre avec la dépression (French)
Vivre avec la bipolarité (French)
Vivre avec une meilleure estime de soi (French)
Vivre avec un meilleur équilibre au travail (French)
I confirm that I have been diagnosed with bipolar disorders by a healthcare professional.
The diagnosis of bipolarity by a health professional is required to participate to the Living with bipolarity workshop.
Please choose the type of workshop you wish to follow between the virtual or onsite formula
Please select...
Virtual
Virtual
Virtual
Virtual
Virtual
Virtual
Virtual
Virtual
Virtual
Virtual
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Please choose the specific workshop you will register for from the options below. Make your choice based on the time slot and start date of each option. Make sure the time and schedule suit you, taking into account that the workshop will end 10 to 13 weeks after the start date.
Are you currently being followed by a doctor ?
Please select...
Yes
No
Are you currently followed by a mental health professional? [psychologist, psychotherapist, psychiatrist, social worker, sexologist, occupational therapist, psychoeducator]
Please select...
Yes
No
Comments
If you have chosen a workshop given in virtual mode, can you confirm that you have a computer, a camera, a microphone and the Zoom application [free] in order to follow it?
Please select...
Yes
No
I confirm that I am technologically comfortable using online tools, i.e. Zoom and the interactive platform where all the content of the workshop will be found.
I understand that all meetings are held with the camera open.
I understand that the self-management workshop in which I wish to participate is a group process. My active participation in the group is important throughout the process for my personal recovery journey, but also for mutual support within the group.
I understand that although the group is a strength and provides a safe environment, it is not group therapy or a support group. It will therefore not be possible to speak at length about my personal experience with the aim of finding solutions or venting.
I understand that the onsite Relief workshops are offered in Montreal - at 418 Sherbrooke Street East.
By checking this box, I consent to the collection and processing of my personal information in accordance with Quebec's Law 25. I understand that this information will be used solely for the purpose of the provided service and will not be shared with third parties without my explicit consent.
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