Grief Support Registration Form 

Grief groups are free and open to the public. All groups meet virtually through Zoom. To participate in a grief group, please submit the following information. You will receive an invitation to an individual Zoom grief session to complete the group registration. All participants are required to sign a Grief Support Group Participation Agreement Form. This form is provided at the initial individual session.

Name

Email

Phone

Name of Deceased:

Deceased age at the time of death :

Relationship to deceased:

When did the death occur?

Were you present at the time of death?

Yes

No

Were you able to say goodbye?

Yes

No

Was there a service (Funeral, Memorial Service, or Celebration of Life)?

Yes

No

If so, did you go?

Yes

No

Please explain the circumstances of the death :

How did you react to it?

What led you to seek help at this time?

Free Text

Grief is the natural human response to loss. When someone we love dies, it affects our lives emotionally, physically, mentally, socially, and spiritually. How does your grief continue to impact any of these areas?

Field label

Please select the group with which you are interested in participating by clicking on the box below: General: open to anyone who has a loved one who died | Meets on the 4th Thursday of every month at 5:30 PM Spouses and Partners: open to anyone whose spouse or partner died and meets on the 2nd Thursday of every month at 2:00 PM Spouses and Partners: open to anyone whose spouse or partner died and meets on the 3rd Thursday of every month at 5:30 PM Parent: open to any parent whose child (prenatal, minor, or adult) died | Meets on the 2nd Tuesday of every month at 5:30 PM

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