Grief Support Group Intake Form

Please fill in as much as you know about the group and provide your contact information in the description of the group if you are not a group facilitator.

Is the group dedicated solely to grief support after a substance-use death? * Required
- Yes
- No
Is the group offering a Virtual Meeting? * Required
- Yes
- No
Focus of the Group
Please select up to three categories that best describe the participants of the group.
- Grief After any Death
- Grief After Suicide
- Grief After Homicide
- Adults Only
- Dads Only
- Moms Only
- Parents
- Siblings
- Had an Adult Sibling Die
- Spouses / Significant Others
- Widows Only
- Widowers Only
- People Who Had a Young Child Die
- People Who Had an Adult Child Die
- Children & Teens with Adults)
- Children Ages 3 - 9 and Their Families
- Teens and Their Families
- Camp For Children - General Grief
- Camp For Children - Substance Use Related Death
- Camp For Teens - General Grief
- Camp For Teens - Substance Use Related
- Grandparents
- Families
- Women Only
- Men Only
- LGBTQ Only
- College Students Only
Group Name * Required
Description of the Group * Required
Address * Required
Address Line 1 Address Line 2 City State ZIP Code
Contact Name
Contact Email
Contact Phone
2nd Contact Name
2nd Contact Email
2nd Contact Phone
Meeting Date / Time
Virtual Meeting Day/Time
Group's Webpage - enter a valid website URL for example https://www.google.com
Sponsoring Organization
Sponsoring Organization's Webpage - enter a valid website URL for example https://www.google.com

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Grief Support Group Intake Form

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