Personal Information




Postal Code*


Age* (month/day/year)



Marital Status*

Additional Information

1. Have you attended at 12 step program before?*

a) If so, when?

b) Which group were you in?

c) Step completed?

d) What program and where? (i.e.. AA)?

2. How did you hear about us?*

3. Do you attend a church?*

a) If so, how long?(input)

b) Which one?

Are you currently under the care of a counselor, psychologist, psychiatrist?*

a) If so, are they in favor of you participating in this program?

b) Explain

Are you currently on any medications for depression, anxiety, insomnia, eating disorders, or other emotional/mental illness?*

a) If so, please explain.

I will be attending Life Renewal Sessions in*


By checking here I indicate that I have read understand and approve and give consent to Life Renewal to use this personal information for my care throughout my 12 step journey, participation in related activities, and emergency care. I understand that my personal information will only be given to directors or facilitator leaders, event coordinators and emergency personnel on a need to know basis. My personal information will be securely stored in an appropriate place for a minimum of one (1) year, and will not be passed on to any third parties without my/our prior consent. *

Furthermore I also understand that any and all child abuse that may come to our knowledge and that falls within the Ontario reporting guidelines will be reported in accordance with Ontario law. ( Child and Family Services act -section 72 ).

We will be contacting you to confirm registration, exact location and start date.