Phone (402) 488-8989

What We Do

Adult Grief Support Group

Adult Grief Support Group Registration

To register for the Adult Grief Support Group, please complete the registration form below.

Please Note: This group is offered at no charge to participants, however, a commitment to participate in all 8 nights of group is required. Mourning Hope attempts to accommodate all registrants for our grief support groups, but programs do fill quickly and space is limited. Upon receiving your registration, Pam Dinneen, Clinical Operations Director, will contact you and confirm space availability; you are not officially registered until that contact has been made. This group is for bereaved adults and is not suitable for children. 

 

Registration

First Name *
Last Name *
Month
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Day
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Year
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Preferred method of contact
Name of person who died:
Date of the death (month/day/year)
Circumstances of the death:
Other changes in your life:
What are you hoping to gain from this group?
Please describe any problems you may be having (may include problems at work/home, behavior changes, physical changes):
Is English your primary language?
The group usually includes refreshments, please list any food allergies:
Please list any physical disabilities or accessibility needs:
Have you or someone in your household attended a Mourning Hope group / program?
Registering for:
By typing your name in the signature box, you are giving consent to participate and possibly be photographed for promotional purposes. The term "electronic signature" means a method of signing an electronic message that identifies and authenticates a particular person as the source of the electronic message; and indicates such person's approval of the information contained in the electronic message.
Month
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Day
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Year