Suicide Bereavement Support Group Enrollment
For those who are seeking support after losing a loved one to suicide.
Our upcoming group meets Monday evenings from 5:30-7:00pm and runs from September 28th-November 16th
Legal Name
*
First Name
Last Name
Name you go by (if different)
What are your pronouns?
Example: she/her, they/them, he/him, etc.
Email
example@example.com
Phone Number
*
Format: (000) 000-0000.
Can we leave you a message at this number?
*
Yes
No
Can we identify ourselves as the Center for Community Counseling when we call this number?
*
Yes
No
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Understanding your loss.
To help us understand your loss and grief more, please tell us a little about who you lost, what your relationship was and anything else you think this is important for your facilitators to know.
What month and year did you experience this loss? (approximate if you are not sure)
Have you experienced more than one loss in the same year?
Yes
No
Please tell us a little about you second loss, what your relationship was and anything else you think this is important for your facilitators to know.
What month and year did you experience this loss?
Have you had thoughts of ending your own life in the last 6 months?
Yes
No
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Emergency Resources
We understand that suicidality can be a normal result of the feelings of loneliness and depression that come with grief. However, the Center for Community Counseling is not an emergency or crisis support center. If you need immediate crisis support call any of the resources below.
*
I understand the statement above and I am aware of services available to me in case of an emergency.
Emergency Contact (required)
In a rare case in which a facilitator becomes concerned about your safety, we will reach out to your emergency contact. Facilitators will only use the contact to confirm that you are safe and will disclose minimal information.
*
I understand that my facilitator may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Emergency Contact Person (must be 18 or older)
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Relationship with the contact person
*
i.e. sibling, spouse, friend, parent, etc...
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Rights and Responsibilities of Group Members
To help all members of the group feel heard and respected, we have these initial ground rules for the group. Please read all to consider if this is the best space for you to process your loss.
Ground Rules of Our Group. (By Tapping EACH box, you agree to the ground rule)
*
Responsibilities of facilitators (By Tapping EACH box, you agree to the ground rule)
*
Protecting each other: (By Tapping EACH box, you agree to the requirement). Since many of our clients do not have access to healthcare services, we take extra care in also protecting our clients' physical health with the requirements below:
*
What do you hope to get out of this group?
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Household Information
How many people are in your household?
Please Select
1
2
3
4 or more
Please list the number of those you support financially (including yourself)
(HH1) Please select the option that best describes your annual income:
under $12,880
$12,881 to $25,760
$25,761 to $38,640
above $38,640
(HH2) Please select the option that best describes your annual income:
under $17,420
$17,421 to $34,840
$34,841 to $52,260
above $52,260
(HH3) Please select the option that best describes your annual income:
under $21,960
$21,960 to $43.919
$43,920 to $65,880
above $65,880
(HH4+) What is your approximate annual income?
Example: $35,000
How many children (18 and under) live with you at least part of the year?
How many adult children live with you at least part of the time?
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Fees and Payments
The Center for Community Counseling is a not-for-profit that strives to provide access to therapy through a sliding scale feel to those who would not otherwise be able to access therapy. We rely on the fees of our clients to continue to offer this service.
Are you a current CCC Client?
Yes
No
Please consider the value of this service and your ability to pay per session when choosing your sliding scale fee.
$40.00 ($5.00/group)
$64.00 ($8.00/group)
$80.00 ($10.00/group)
$96.00 ($12.00/group)
$120.00 ($15.00/group)
$160.00 ($20.00/group)
$200.00 ($25.00/group)
$240.00 ($30.00/group)
$280.00 ($35.00/group)
$320.00 ($40.00/group)
Please consider the value of this service and your ability to pay per session (in addtion to your other weekly CCC fees) when choosing your sliding scale fee.
$8.00 ($1.00/group)
$24.00 ($3.00/group)
$40.00 ($5.00/group)
$64.00 ($8.00/group)
$80.00 ($10.00/group)
$96.00 ($12.00/group)
$120.00 ($15.00/group)
$160.00 ($20.00/group)
$200.00 ($25.00/group)
$240.00 ($30.00/group)
$280.00 ($35.00/group)
$320.00 ($40.00/group)
I would like to be billed for the group in:
*
A one time electronic invoice for the entire amount that I can pay with credit or debit card, Venmo or Paypal.
I will bring cash or a check payment to each weekly group.
I have a special circumstance and need to work out a payment plan with CCC staff by calling or emailing the contact below.
I understand I will be asked to pay the 8- week group rate at/after the first session. If I need financial assistance, I will email counseling@ccceugene.org or call 541-344-0260 for scholarship or payment plan options.
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VOLUNTARY Demographic Information
Responding to this section is voluntary and will help us assess our service to various communities. The information you share will not be used to identify or determine your immigration status, and will not be reported to anyone. You may choose not to answer any question(s).
What is your racial or ethnic background?
What is your marital or relationship status?
What is your gender?
Do you have a Deaf, neurodivergent, chronic illness, or disability identity that you would like to share with us?”
Attestation:
*
Signature
Today's Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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