Eligibility Check:

Are you 17-26 years old?Do you live in Vancouver/Richmond?Do you identify Mental Health Barrier?

Signup Form

First Name *
Last Name *
Phone Number *
Cell Phone
Your Email *
Address *
City *
Postal Code *
Date of Birth *
Gender *---FemaleMaleThey/ThemPrefer not to say
Do you identify as having a mental health condition? *---YesNoI'm not sure
If yes to above question, please choose: (Check all that apply)
AnxietyDepressionBipolarSchizophreniaPTSDPsychosisOCD
Additional concerns or other health conditions:
Do you receive support from: (Check all that apply)
VGH (inpatient/outpatient)UBC (inpatient/outpatient)St. Paul's Hospital (inpatient/outpatient)AACMental Health TeamEPIHUB
Other
Please provide a referral contact name and Agency *
Please provide a referral contact phone number *
By checking the box, you give consent to us contact your referral
Where did you hear about Summer Session program *?

Emergency Contact:

Full Name *
Relationship *
Phone *
Email *

Parent Consent and Signature (if under 19)

Please be advised that,
age has registered to SUMMER SESSIONS 2022. OPEN DOOR GROUP organizes and run these social, recreational events for young adult ages 17-26years, who are experiencing mental health issues.

Your signature below indicates that you have been informed of and consent to your minor’s (under the age of 19) participation. No minor will be allowed to participate without a signed consent form
Parent or Guardian: (Print Name)

Signature: (Draw in the box below)

Date: