Phone (402) 488-8989

What We Do

Online Survivors of Suicide Loss Registration

Virtual Survivors of Suicide Loss Support Group Registration

To register for the Survivors of Suicide Loss Support Group offered online via Zoom, please complete the Registration Form below.

  • This group is appropriate for adults ages 18+

Registration Form

First Name *
Last Name *
Country
Address Line 1 *
Address Line 2
City *
State/Province *
Postal Code *
Cell Phone:
Preferred method of contact:
Name of the person who died:
Date of death (month/day/year):
Please confirm the cause of death:
Decedent's relationship to you:
If "Other", please detail here:
What are you hoping to get from this group?
Have you experienced any other changes in your life:
Name(s) of other adult(s) attending:
Is English the primary language spoken in the home?

Funding agencies often require nonprofit organizations to maintain client information related to gender, race, age and income level. The requested information is strictly for the purpose of Mourning Hope's compliance with these record-keeping requirements. Responses will remain anonymous, and are greatly appreciated.

Age of Participant(s)
Please check all that apply:
Gender of Participant(s)
Please check all that apply:
Race of Participant(s)
Please check all that apply:
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.