Your Name (required)

Your Email (required)

Age:

Address: (required)

City: (required)

Zip Code: (required)

Phone: (required)

Work Phone: (required)

Have you sought counseling to help deal with this loss?
YesNo

If yes, please specify:

Are you currently on any medications to help you with the loss?
YesNo

If yes, please list:

Are you presently involved in any other support groups?

If yes, please list:

What other major losses have you experienced within the last year?

What do you hope to get from this support group?

Who might we contact in an emergency?

Name:

Phone:

What number can we call if there is a last minute need to cancel the group?

Confidentiality and Treatment Agreement

In keeping with the Federal regulations regarding the privacy of health care information, we request that you complete the following:

I (yourself, or parent/guardian if appropriate), understand that, although Hope and Healing with Peers values and maintains confidentiality for each person who participates in our groups, there are certain circumstances in which confidentiality cannot be maintained. The following are such circumstances:

1. In the event of possible suicide or homicide, professionals, family members or other persons directly involved may be notified without the permission of the participant, if the participant or another person is in life-threatening danger or crisis.

2. The group facilitator is required by law to report information such as, physical, emotional or sexual abuse if participant reports such knowledge of these abuses without the participant’s permission.

3. If it is found that a participant has breached the confidentiality of other participants, they can be asked to leave the group.

Hope and Healing with Peers support groups are focused specifically on grief education and support. Sometimes people may need assistance beyond the support group program. Not all groups are right for all people. We reserve the right to talk with you about your ongoing participation in the group, and offer suggestions as to whether more appropriate support services are needed.

Participant:

Date:

(Date Format: DD-MM-YYYY)

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