Homicide Survivor Support Group Therapy Participant Registration/Intake Form 
If you have any trouble with this form, please feel free to reach out to Scharnelle Hamlin at 804-331-4057.ext 103.  We ask that you please complete ALL information on this form so that we can have accurate data. It is essential that all fields are completed. Thank you ! 
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First and Last Name  *
Today's Date:  *
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Date of Birth:  *
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What is your  FULL address? Please include your city, state and zip code. *
What is your phone number? Please include area code) ###-###-#### Format Please.  *
What is your email address?
Please list an emergency contact name, phone, number and relationship to you: Ex. John Smith -  ###-###-####- Dad *
What is the name of your loved one who was taken? 

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What relationship was your loved one to you?
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Date of your loved ones death:  *
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Was your loved one taken due to gun violence?  
If your loved one did not die due to gun violence, what was the cause of death?
Your race/ethnicity: *
Required
Your Gender Identity: *
Required
Do you identify as any of the following?  *
Required
Do you require any special accommodations in order to attend group?  *
Please share with us how you learned about the group: *
Required
What do you hope to gain from attending the HSG? (Check all that apply) 
Are there any helpful skills or activities that you feel will be beneficial to the group?
Is there anything additional that you feel we need to know about you so that we may better serve you throughout your grief journey?
Please print your name to acknowledge the terms: I understand that Homicide Survivor Support Group services are voluntary and confidential except: 1. When a participant is a danger to themselves or others. 2. When a participant shares a new report of suspected child or vulnerable adult abuse that has not been reported. Your facilitator is required by law to report the exceptions listed above.    *
Upon request, I agree to abide by VVAN Group Facilitator requests to wear a mask and socially distance for groups meeting in-person. I agree not to attend group if I am experiencing flu-like or COVID symptoms.  Please print your name below as acknowledgement. 
Please put today's date as an acknowledgement of these terms: By signing this form, I agree to participate in this group and maintain the confidentiality of other group members. I agree not to post information about the group or its members on social media without their permission. If I am a group participant, I agree to allow an exchange of information between the Facilitator, my local Victim/Witness Office, and the Virginia Assistance Network, for purposes of group participation and Grant Funding. I agree to an exchange of information with an individual therapist for purposes of referral and resource provision. I understand that all information provided is confidential and voluntary.  *
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