Support Group Interest
Please select your group interest:
*
Adult Support Groups
Children/Teen Support Groups (only offered during summer months)
I am interested in joining:
*
Summer 2026 Groups (registration ends May 21)
Interested Participant Information
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Please Select
Male
Female
Non-binary
Prefer not to answer
Child/Teen Name:
*
First Name
Last Name
Child/Teen Date of Birth:
*
-
Month
-
Day
Year
Date
Child/Teen Name:
First Name
Last Name
Child/Teen Date of Birth:
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary phone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
Loss Information
Name of loved one who died:
*
First Name
Last Name
Age:
*
Date of death:
*
-
Month
-
Day
Year
Date
What was your relationship to the deceased?
*
Cause of death:
*
Name of loved one who died:
First Name
Last Name
Age:
Date of death:
-
Month
-
Day
Year
Date
Relationship of deceased:
Cause of death:
You must complete a group readiness assessment and pay a one time fee to participate in a support group.
*
Please reach out to me to arrange a Group Readiness Assessment. I understand that this one-hour session is available exclusively in person at your Independence office, and there is a $75 fee for the assessment, which is not covered by insurance.
I would like to discuss your groups further and gather additional information.
Submit
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