Group Support Intake

Thank you for your interest in joining Carson’s Village Grief Group Support. This group is a peer support grief group facilitated by a professional counselor intended for individuals aged 21+ years. Our group support coordinator will reach out to you with meeting details after your intake form has been reviewed.

Name*
First Last
Phone*
Email*
Age*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Deceased Name*
First Last
Relationship to the deceased & date of death*
Any other losses – Who and When?
Have you attended grief group support in the past?*
- Yes
- No
If yes, how long, when, where, and what was your overall experience with grief group support?
Are you currently under the care of a physician?*
- Yes
- No
Reason for care.
Are you currently seeing a professional for issues related to mental health (counselor, psychiatrist, PCP, etc.)?*
- Yes
- No
If yes, how long, when, where, and for what reason?
What are your expectations of group support?*
Do you have any concerns about your ability to participate in group support?*
Do you need support with connecting to zoom on your computer?*
- Yes
- No
If yes, please provide details.
Do you have any questions?

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Need support right away?
Call us at 877-789-0722 or email us HERE.

Stay up to date on what's happening
at Carson's Village.

Want to know what else Carson’s Village is up to? Join our email list.

Need support right away?Call us at 877-789-0722 or email us HERE.

Need support right away?
Call us at 877-789-0722 or email us HERE.