Pet Loss Support Group
Name
*
First Name
Last Name
Pronouns
Pet's Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
This group will be offered once per quarter. Please select the session you would like to participate in.
February 2025
May 2025
August 2025
November 2025
Would you like the Veterinary Social Worker to contact you for one-on-one support prior to the start of the group?
Yes
No
Length of time since loss (at the time of completion of this document):
1 month or less
2-6 months
6 months to year
Longer than 1 year
How are you feeling about your loss right now? (Check all that apply)
Sadness
Anger
Guilt
Loneliness
Numbness
Other
What are your hopes and/or goals for participating in this group?
How comfortable do you feel sharing your feelings and experiences in a group setting, and hearing others’ stories that may be emotionally activating?
Not Comfortable
Somewhat Comfortable
Comfortable
Very Comfortable
Are there any specific challenges or concerns you’re facing related to your loss, do you need any accommodations to facilitate your participation in the group, or is there anything else you feel the facilitator should know in order to support you?
Thank you for completing this questionnaire. The facilitator will review your responses and reach out to you with the next steps to finalize your registration. If you have any questions, feel free to contact us.
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