Grief Support Group Registration
This group is intended to provide education, support and connections among those ages 18 or older who may be grieving. It's purpose is to provide a safe space to learn coping skills, techniques, establish connections with others, and understand the grievance process. 
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Email *
Name of Individual Registering  *
Are you 18 or older? *
Phone Number *
Email Address *
Have you encountered or experienced a recent loss?
If you do not wish to answer in detail, reply with the amount of information you are comfortable sharing.
 *
How long ago was this incident? 
If you do not wish to answer in detail, reply with the amount of information you are comfortable sharing.
What are your personal hopes for this group? *
What would you like to see discussed in this group? *
How do you intend to pay for this group session? *
IF using insurance: Please provide in the box below the name of your carrier, Member ID, the primary policy holder's name and date of birth.

OR, if you are seeking financial help to cover the cost of the group, please specify below.
 *
Any other questions/comments/concerns:
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