Registration Form

Are you a new or returning member?

New

Returning

Have you ever attended grief support groups in the past?

Yes

If yes, where?

Which support group are you interested in attending?

Adult Grief

Survivors of Suicide

Ambiguous Loss

Full Name

Phone

Address

Emergency contact (name)

Emergency contact (phone)

Their name:

Their age:

How did they pass?

Are you currently working with a therapist?

Yes

Would you like a therapist referral?

Yes

How did you hear about us?

BY CLICKING "COMPLETE REGISTRATION" YOU ACKNOWLEDGE THE ITEMS BELOW:

I acknowledge that this is a support group facilitated by trained facilitators not therapist.
I acknowledge that I will keep stories shared in group confidential among group members.
I acknowledge that I will not come to group under the influence of alcohol and/or recreational drugs other than prescription medication.
I acknowledge that that maximum participation equals maximum value and am prepared to be present in active listening when others are sharing with my camera on visible throughout the group session.
I acknowledge that if grief becomes overwhelming, I will reach out to Adena for additional support.
I acknowledge to read, review, and respect the guidelines of the group or risk being terminated from the group.

Annual Group Fee

$100

Signature

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