Grief Support Group Interest Form

About Our Program

This grief support group is co-facilitated by the Hendrick Hospice Care Bereavement Coordinator and Bereavement Specialist. Sessions generally include a time for checking in/reflecting on the homework, grief education, discussion, and therapeutic activities. Participants are given a handout and homework each week in the hope that these will provide opportunities to continue grief work outside of our time together.

Notice

Please note that this form does not constitute a reservation nor does it obligate you to attend.

Tell Us About Yourself

All information submitted on this form will be held in strict confidentiality between group facilitators.

Name*

Phone Number*

Email Address*

Email is the quickest way for us to notifying you of upcoming groups.

Mailing Address*

City*

Zip Code*

My loved one's name is...*

Relationship*

Who is your loved one to you?

My love one died...*

Was your loved one on Hendrick Hospice Care services?*

Please note that our grief support is available to you regardless of whether or not you used our hospice services.

Select or enter value

What else we should know about you/your loss?

For example, have you had any other recent losses/stressors (e.g. divorce, financial hardship, relocation, mental or physical illness, etc.)? Please include anything that you feel may be relevant in helping us to provide the best care and support.

What would make this group beneficial for you?*

What is your hope in attending this group? Are there particular topics, issues, concerns, needs, or questions that you'd like addressed?

How did you hear about us?*

Consent*

I understand that if I choose to participate I am consenting to sharing my participation and identity with the other participants in the group.

Send me a copy of my responses

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