Grief Support Intake Form - Walking Through Grief
Congratulations on taking another step in your journey to healing! Please complete this form in order  to attend Walking Through Grief. The demographic information is used to help us serve our community better by identifying gaps and areas of need.  Your responses are kept private and secure, and will not be used for a discriminatory purpose. 

Our group runs out of the Norval United Church usually on Wednesday evenings. Meetings typically run from 7:00 - 8:30 pm. 

PLEASE NOTE: OUR FALL SESSION IS NOW CLOSED TO REGISTRATION. YOU CAN COMPLETE THE FORM TO BE CONTACTED ABOUT THE SPRING SESSION.

After this form is completed, one of our group facilitators will confirm the dates with you. 
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First Name *
Last Name *
Which session are you hoping to join? *
This is a  Closed Grief Group, which means participants are asked to attend all sessions.  *
In which Town/City/Municipality do you live? *
If you indicated Other above, please tell us your Municipality, City or Town
Email Address *
Phone Number *
How did you hear about our Grief Support Group? *
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? *
Please list any accessibility needs here.
Ex. difficulty hearing, vision difficulty, mobility. 
Do you have any pre-existing mental health challenges? *
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.
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