Support Group (for Suicide Loss) Interest Form

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Thank you for your interest in attending one of the new Johnson County Support Groups for individuals who have lost someone to suicide. We're sorry for your loss, but hopeful your involvement with the group will bring healing and connection.

To help us know who will be showing up, and to ensure you're in the right place to find the group beneficial, we have a few questions for you below. Please fill this out for each person interested in attending each group.

Johnson County will be launching three separate groups in 2024, each meeting on different days and times. Which are you interested in attending?

The Adult (18+) Survivor of Suicide Loss Open Group - meeting once a month, on the second Wednesday (currently at the Franklin JCPL Branch), from 7-8:30, this group is for adults, with no attendance requirements

The Teen (12-18) Survivor of Suicide Loss Open Group - meeting once a month, on the second Tuesday of the month in the Greenwood/Center Grove area, from 7-8:30, this group is for teens, but must have an adult present onsite (we'll have you in a different space), with no attendance requirements

The Adult (18+) Curriculum-Based/Book-Based Suicide Loss Support Group - meets once a week for 10 weeks (from 7-8:30), with the expectation of attendance at each meeting - likely starting in the summer/fall 2024

None of these work for me at the moment, but I'm interested in hearing about future options!

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Name of Attendee *

Name of Person Completing form (if different from above)

Phone Number *

Email Address *

Please share your relationship to the person who died by suicide (including the month/year they died), and anything else you'd like to share about your loss of someone to suicide
*

What are you looking for in a suicide-loss support group? *

Are there any special needs that we need to be aware of?:

If you're an adult, completing this for a teen to attend the teen group - what does the teen know about the death?

If you're an adult, completing this for a teen to attend the teen group - how does the teen act in groups?

Emergency Contact 1: Name/Relationship/Phone Number *

Emergency Contact 2: Name/Relationship/Phone Number

Group Overview and Expectations

Adult Group: This is a 90 minute group from 7p to 8:30p, meeting on the second Wednesday of each month at the Johnson County Public Library's Franklin Branch. Each meeting will consist of an opening circle, open discussion, and a closing circle. Attire should be comfortable for the attendee. Our facilitators are finalizing initial group expectations, and we will email them to you prior to your first meeting.

Teen Group: This is a 90 minute group from 7p to 8:30p, meeting on the second Tuesday of each month in the Greenwood/Center Grove area. We do expect and require each teen to have an adult on premises during the group (in case of emergency), however, teen's adults will not be permitted to attend the group. Everything that happens in the group will remain confidentially unless we are concerned about their safety. Since we don't expect teens to sit in a circle for 90 minutes (as the Adult group does), their meeting will consist of an opening circle, activity, free space, closing circle. Attire should be comfortable for the teen, and allow them to move around and be active. Our facilitators are finalizing initial group expectations, and we will email them to you prior to your first meeting.

Closed Group: This is a 10 week course that meets weekly (currently on Mondays) for 90 minutes. Because it is curriculum-based, we consider it a "closed group" and require individuals to register and attend. We do not yet have dates for the next group, but are taking names of individuals interested in attending!

I have read the group overview and expectations for my group of interest, and agree to follow these expectations.

Yes

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Next Steps

Thank you for filling out this form! Upon hitting "submit" below, your form will be routed to the appropriate group facilitator. You'll next get an email from atlas@upstreamprevention.org with the group expectations, location of the next group meeting, and information about your facilitators. If they have any questions, they will reach out by either phone or email. If you have any questions, you can reach out to either atlas@upstreamprevention.org or call Kathleen (Upstream's Executive Director) at 317-824-9617, and she can have someone contact you.

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