Group Registration

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Group Registration

Registration begins with gathering a little information about how to contact you and how you are doing. Julie will review your information prior to the start of the group.

This form is a great Self Assessment Tool. This will give you a chance to explore how you are experiencing grief at this moment as you begin. It's important to capture this for yourself in order for you to see your own transformation through your griefwork.

You will complete a Group Post Program Self Assessment at the end of the program where you will be able to review your experience.

Email *

First Name *

Last Name *

Street Address *

City, State Zip *

Best Contact Phone Number *

Date of Loss *

Relationship to your Loved One/Situation *

Loss of Spouse or Life Partner

Loss of Parent

Loss of Child

Loss of Sibling

Multiple Losses

Caregiving

Other type of loss/transition/situation

Other:

Required

I am tearful more than I expected. *

Not at all, I expect my level of tearfulness

I cry everyday

I worry excessively. *

No, not more than usual

Yes, much more

Thoughts about my loss/situation are consuming my time and life. *

No, not more than usual

Yes, much more

I have trouble falling or staying asleep after my loss /life experience. *

No, not more than usual

Yes, much more

I feel disconnected from my friends and/or family or I'm not enjoying interests that I used to. *

No, not more than usual

Yes, much more

I have trouble staying on task or getting motivated to do activities. *

No, not more than usual

Yes, much more

I avoid situations, places or people that remind me of my loved one/situation. *

No, not more than usual

Yes, much more

I struggle with my spirituality since my loss/life experience. *

No, not more than usual

Yes, much more

I'd like to register for this group: *

Your Friend in Grief - 8 weeks newly bereaved group $20/week ($160 total)

Your Story of Grief - 8 weeks story telling grief group $20/week ($160 total)

The Story Continues... - 8 weeks of continued story telling grief group $20/week ($160 total)

Mending Me - 8 weeks of exploring Your New Way of Living group $20/week ($160 total)

HeART Connection - 8 weeks Inspired, Meditative Art group $20/1 day ea. week ($160 total)

HeART Connection - 8 weeks inspired, meditative art group $40/2 days a week ($320 total)

Other:

Required

Payment Link

Make your payment here: https://paypal.me/ChartreuseCenter

Chartreuse Center Payment QR code

Next Steps...

You will automatically receive a copy of your responses to the email you provided. Hold onto your self assessments so you can see, for yourself, the transformation you will experience through exploring your grief.

After I review your registration, and payment is confirmed, you will receive the Zoom link for your the program. The email will come from Julie@ChartreuseCenter.com. If I have any questions before we start, I'll reach out by phone.

This is a tough time, right now. I can tell you, each lesson offers a new opportunity to explore, learn, or grow within your grief. I'm here to help you through. I look forward to learning beside and about you.

Your Friend in Grief,
Julie

A copy of your responses will be emailed to the address you provided.

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