Grief and Loss Group
Please fill out and submit registration for below. We will notify you when dates are set for the next group.
Parents or Guardian Name
First Name
Last Name
Number of participants including yourself
Names and birthdates of all participants
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you and/or participant currently a WSCC Client?
Yes
No
If yes, who is the participant's counselor?
Insurance?
Private
Medicaid
None
None, but interested in learning about sliding scale program
If you have insurance, please provide carrier name, group and/or ID number.
How did you hear about our grieving group?
Social Media (Facebook, Instagram, LinkedIn, Twitter)
Networking event or conference
Enewsletter/Eblast from WSCC
Word of Mouth
Ad online
Other
Questions/Comments
Submit
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