Postpartum Mental Health Group - Request to Register

Please be aware that completing this form does not ensure you are registered yet. You must first be screened for eligibility by the group facilitator (see below for more information). Additionally, you will not be registered (or charged) in the event that the class or workshop is full, or if your form is received after the registration cut-off date. Either way we'll be in touch with more information!

Your Name*
First Last
Your Email*
Your Phone Number*
Your Age*
You must be 18+ to participate.
The age of your child (or children) in months:*
Your Address*
Street Address Address Line 2 City Province Postal Code
Screening
Screening*
I understand that I must first be screened by the group facilitator before being registered for this group. I understand that no charges will be incurred until I am confirmed for the group by the group facilitator.
Contact for Screening*
I understand that either my email or phone number will be used to contact me in order to schedule my screening. This initial screening will be a 15-minute phone call with the group facilitator.
Payment
Payment will only be taken if your eligibility for the group is confirmed by the group facilitator. Online registration for classes and workshops must be paid for by credit card. Please refer to the corresponding workshop or class webpage to find the cost. If you would like to pay using an alternate payment method, please contact our reception at 604-284-7827 ext. 0.
Cardholder Name*
First Last
Account Type*
Account Number*
Expiration Date*
Please enter "01" for the expiration day. Thanks!
Year
Month
DD
3 Digit Security Code*
You can typically find this number on the back of your credit card.
My billing address is the same as the address listed above*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Consent*
I understand that classes are offered as a whole, and refunds will not be available for missed sessions.
Consent*
I authorize the above named business to charge the credit card indicated in this authorization form, according to the terms outlined above, and according to the Alongside You cancellation policy. I authorize Alongside You to charge my account for services rendered, including retainer payments. This is permission for recurring transactions related to clinical services, and does not provide authorization for any additional unrelated charges or credits to the account. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Cardholder Signature*
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Postpartum Mental Health Group - Request to Register

Screening

Payment