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What is Life Renewal?
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Contact Information
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Personal Information
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Program Information
Have you attended a 12 step program before?
Yes
No
If so, let us know which program, and what steps you completed
How did you hear about us?
Do you attend church?
Yes
No
If so, where and how long?
Are you currently under the care of a counselor, psychologist or psychiatrist?
Yes
No
If so, please explain:
If you are under care, are they in favour of this program?
Yes
No
Are you currently on any medications for depression, anxiety, insomnia, eating disorders, or other emotional/mental illness?
Yes
No
If so, please explain:
I am attending Life Renewal Sessions in:
Select
Ancaster Canadian Reformed Church
Burlington - Ebenezer Canadian Reformed Church
Carman East - Canadian Reformed Church
Edmonton - Immanuel Canadian Reformed Church
Elora Canadian Reformed Church
Niagara Daytime - Covenant CanRC Grassie
Lacombe/Blackfalds
Langley - Christ Covenant Church
Lynden, WA - American Reformed Church
Ottawa -Jubilee Canadian Reformed Church
Smithers Canadian Reformed Church
Smithville Canadian Reformed Church
Toronto - Covenant Reformed Church
Winnipeg - Grace Canadian Reformed Church
Yarrow
Accept
I 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, even 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 consent. Furthermore, I also understand that any and all child abuse that may come to our knowledge and that falls within the reporting guidelines of your province will be reported in accordance with Ontario Law. (Child and Family Services act - Section 72)
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