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Writing Your Grief
A Young Adult Support Group
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Contact Information
Name
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Email
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I give permission for my email address to be used by Full Circle to communicate information regarding future programs, services, and events.
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Birthday
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Gender Identity
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Address
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Cell Phone Number
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Emergency Contact Name
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Emergency Contact Number
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Name of the person who passed away
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Relationship of the deceased person to you
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Date of Death
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Cause of death
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Location of death
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Details surrounding death
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Personal Information
Have you had experience with support groups in the past? If so, describe your experiences.
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Have you participated in the past or are currently participating in a Full Circle program? If so, which one?
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HOH Family Group
Perinatal Loss Group
Suicide Loss Group
Overdose Loss Group
Homicide Loss Group
Individual Counseling
Have not participated in a Full Circle Program in the past
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For past or current Full Circle client/group participants, please check yes or no to give the Partner Loss Group leader permission to share your participation with your therapist/group program leader.
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What are the greatest challenges you have experienced in your grief?
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Describe your current support system (i.e., friends, family, religious community, etc.).
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List any community resources you have utilized for support or services during this time (i.e., counseling, support groups, physicians, church programs, community programs, etc.).
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The prospect of writing about my grief...
Excites me
Intimidates me
Makes me feel hopeful
Other:
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Anything else you feel we should know?
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CONFIDENTIALITY AND RIGHT TO PRIVACY EXCEPTIONS
Our work with you is confidential and will not be shared with anyone outside of Full Circle. Information shared with group leader is confidential and will only be discussed when consulting with a clinical team member at Full Circle. Your rights to privacy will be strictly maintained. However, there are some important exceptions to confidentiality and privacy which are explained below.
Exception One: Virginia law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.
Exception Two: If we learn that someone with whom we are working has a specific intent to bring harm to himself/herself, we reserve the right to inform other family members, contact local authorities, and/or make appropriate referrals.
Exception Three: If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent. If we suspect a participating adult is using drugs and/or alcohol before a group, we reserve the right to prohibit the person from participating in that day’s program.
Exception Four: If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release of information, the court may nevertheless require compliance with the order.
Exception Five: If we learn that someone participating in the program intends to commit a violent act, we may take steps to protect the intended victim against such danger, inform the police/authorities, or both.
Exception Six: The rights and exceptions to privacy apply to information disclosed in peer groups. All members are expected to keep information confidential, but Full Circle cannot guarantee they will do so.
Exception Seven: At times, Full Circle will use case examples in publishing articles, creating marketing information, conducting educational programs, and in fundraising efforts. We may anonymously refer to your situation in those circumstances. Your name will never be used without your specific written approval.
In signing below, I acknowledge that I have had the opportunity to ask questions about Full Circle’s Confidentiality policy. I have read and understand the “Right to Privacy Exceptions”. I fully understand and accept my rights to privacy and exceptions to right to privacy.
Signature: (Typing your name here represents your signature)
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