Application for Hospice Grief Services

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The Community Hospice provides free short-term 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, 47 Liberty Street, Catskill, NY 12414

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

An Intake Coordinator will call you to discuss the programs and services we have available. Services may include:

-Counseling for adults and children
-Support Groups, including Widow/Widowers, Living with Loss etc.
-Camp Erin, a weekend camp for grieving children and teens, 6-17 years old
-Wave Riders, program for grieving children and teens, 3-17 years old

These services are free of charge and in person. If you are out of the area, please contact your local Hospice. Additional supports are available for schools and organizations in our community, support groups, memorial services, outreach and a community support team.

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

Applications must be submitted by individuals requesting services or the legal guardian.

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

First Name *

Of the adult seeking services, or the legal guardian if a minor.

Last Name *

Of the adult seeking services, or the legal guardian if a minor.

Email Address *

Gender

Date of Birth

Ethnicity

Phone Number *

Best number for contact during normal business hours. You may list more than one phone number. Please include area code.

Mailing Address *

City *

State *

Other:

Zip Code *

Emergency Contact- Name *

Emergency Contact- Phone Number *

Emergency Contact- Relationship to Client *

Mental Health Counseling Experience *

I have never seen a counselor or received mental health treatment before.

I have received counseling/mental health treatment in the past.

I am currently receiving counseling/mental health treatment.

Mental Health Diagnoses

Services Requested *

Adult Grief Services

Children's Grief Services

Both

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