Application for Hospice Grief Services
The Community Hospice provides free grief support services to those who are grieving the death of a family member or friend. Services are provided at the following locations:

The Community Hospice, 445 New Karner Road, Albany, NY 12205
The Community Hospice, 295 Valley View Blvd, Rensselaer, NY 12144
The Community Hospice, 179 Lawrence Street, Saratoga Springs, NY 12866
The Community Hospice, 246 Manny's Corners Road, Amsterdam, NY 12010
The Community Hospice, 47 Liberty Street, Catskill, NY 12414
Sunnyview Rehabilitation Hospital,1270 Belmont Ave, Schenectady, NY 12308

More information on our services can be found on our website www.hospicegriefservices.com

A Bereavement Counselor will meet with you and your family to discuss the programs and services we have available. Services may include:

-Individual or Family grief counseling, for adults and children
-Support Groups, including Widow/Widowers, Daughters Group, Living with Loss etc.
-Camp Erin, a weekend camp for grieving children and teens, 6-17 years old
-Wave Riders, a six week program for grieving children and teens, 3-17 years old

These services are free of charge, and are available to everyone, regardless of whether the person who died was a Hospice patient. Additional supports are available for schools and organizations in our community, including training, support groups, memorial services, outreach and a crisis support team.

Once you have submitted your request, we will contact you within 5 business days.

Applications must be submitted by individuals requesting services and legal guardians.

Please call 518-724-0200 if you have any questions or concerns. Thank you for your interest.

Email address *
First Name *
If a minor, please enter the parent or legal guardian's first name.
Your answer
Last Name *
If a minor, please enter the parent or legal guardian's last name.
Your answer
Date of Birth
If a minor, please enter the parent or legal guardian's date of birth.
MM
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DD
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YYYY
Gender
With which gender do you identify?
Phone Number *
Best number for contact during normal business hours. You may list more than one phone number. Please include area code.
Your answer
Mailing Address
Your answer
City
Your answer
State
Your answer
Zipcode
Your answer
Ethnicity
For statistics.
Your answer
Marital Status
For statistics.
Your answer
Military Status
Is anyone in your family in the military?
Low Income
For statistics. Is your household income less than $36,375 a year?
Services Requested
Whom are you requesting services for? Check all that apply.
Children's Services - Camp Erin, Wave Riders, or Counseling
If you are applying for any services for children, including Camp Erin, Wave Riders, or counseling, please complete the section below. Otherwise, please skip this section.
Legal Guardian
Are you the legal guardian of the children you are requesting services for?
Child #1
Please include: First name, last name, age, gender, and date of birth. Ex: Mary Smith 10 Female 1/1/2006
Your answer
Child #2
Please include: First name, last name, age, gender, and date of birth. Ex: Mary Smith 10 Female 1/1/2006
Your answer
Child #3
Please include: First name, last name, age, gender, and date of birth. Ex: Mary Smith 10 Female 1/1/2006
Your answer
The children lost their:
The person who died was the children's...
Loss History
Please share with us some information about your most recent loss.
Loved One's Name
Please share with us the first and last name of the person who most recently died.
Your answer
Date of Death
Approximate date of the most recent loss.
MM
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DD
/
YYYY
Relationship
The person who died was your (the adult's)....
Cause of Death
Please share with us how the person died.
Services
Please share with us what services you have received in the past, and what services you are requesting more information about.
Hospice Patient?
Did your loved one receive Hospice patient services from The Community Hospice? Grief services are available to everyone, free of charge, regardless if their loved one was a Hospice patient or not.
Previous Services
Has your family previously participated in any of our services? Please check all that apply.
Services Requested
If you are requesting more information on any specific services, please indicate below.
Referred By
Please share with us how you heard about our services.
Your answer
Reasons for Seeking Support
Your answer
Additional Information
Please include any additional information you would like to share with us - other losses, life changes, behaviors, physical limitations, medical or mental health concerns or diagnosis?
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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