Grief Support Intake Form

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Thank you for your interest in our Grief Support Program. Our program runs for 8 consecutive weeks and attendance at all sessions is required. Please complete the form below and one of our volunteers will get in touch with you. We plan to offer a winter session in 2026 but dates are still TBD.

First Name *

Last Name *

Which session are you interested in attending? *

Winter

Spring

Fall

Any

Required

In which Town/City/Municipality do you live? *

Georgetown

Acton

Norval

Other:

If you indicated Other above, please tell us your Municipality, City or Town

What is the best email to reach you? *

Phone Number *

How did you hear about us? *

Jones Funeral Home

Norval United Church

Family/Friend

Doctor or Therapist

Other church

Other funeral home

Social Media

Other:

Name of your loved one *

Relationship to you *

Month& Year of your Loved one's death *

Have you attended any other peer support groups for this loss? *

Yes

Please list any accessibility needs here.
Ex. difficulty hearing, vision difficulty, mobility.

Do you have any pre-existing mental health challenges? *

Yes

Prefer not to answer

If you answered yes to the above, please specify below
Ex. Anxiety, depression, ADHD etc.

I acknowledge that the support provided is peer support and not counseling or therapy. Our peer supporters have their own experiences with loss, and while we cannot guarantee a match based on specific losses or life experiences, we are here to support anyone needing a grief peer support group. *

Yes

Required

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