Grief & Loss Support Group – Winter 2026 "*" indicates required fields Name* First Last Date of Birth* MM slash DD slash YYYY Requested for insurance billing and electronic health records.Name of Second Attendee (if applicable) First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Age Range* Under 18 18 – 24 25 – 34 35 – 44 45 – 54 55 – 64 65 or older Prefer not to say Gender Identity* Woman Man Non-binary Prefer to self-describe Prefer not to say Race/Ethnicity (select all that apply)* Black or African American Hispanic or Latino/a/x White Asian Native American or Alaska Native Middle Eastern or North African Native Hawaiian or Pacific Islander Multiracial or Multiethnic Other Prefer not to say Are you currently receiving mental health services?* Yes No Prefer not to say Whose memory will you be processing with the support group?*When did they pass away?*Which of the following best describes their death:* Sudden Expected Accidental Please feel free to share any additional information you'd like our clinician to know ahead of time.NOTE: This information is confidential and is only for the group facilitators. Untitled First Choice Second Choice Third Choice
