Grief Support Group Registration

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Register here for the Vision Counseling Grief Support Group. The group is free but limited to a small number of participants. Please help us to prepare by completing this form to provide us with more information about yourself, how you learned about this group, and how to best support you.

Email *

Participant First & Last Name *

Participant Phone Number *

Is this your first time participating in a support group? *

Yes

How did you hear about the Grief Support Group? *

A representative/staff of Vision Counseling

Vision Counseling website

Social Media

Word of Mouth

Flyer

Other:

Please indicate who or what your grief/loss is connected to (Select all that apply). *

Spouse/ Significant Other

Parent

Child

Sibling

Other family member

Friend

Pet

Job

Marriage/ Romantic Relationship

Health

Possession (i.e. home, vehicle, item of significant value, etc.)

Other:

Required

Do you require any specific accommodations (i.e. handicap accessibility, reader, interpreter, etc.)? If so, please state it below.

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