Group Grief Support Registration Form

Group Format: This will be a closed group, meaning it is not an "open group" or "drop-in group," which allows participants to join at any time. Pre-registration is required.

Agenda: A structured session format will be followed.

Duration & Dates: Five (5) 90-minute sessions

Investment to participate: $95 (+ HST) for the entire program of five (5) sessions. This is private pay.

Once the group organizer and facilitator has received your registration form, you will be contacted to schedule a 20-minute chat and upon acceptance to the group, invoiced for participation. There are no refunds once accepted in the group as that spot has then been assigned and is no longer available to another person.

Name*

First NameLast Name

Birth Date

MonthDayYear

Gender:*

Address*

Street Address

Street Address Line 2

CityProvince / State

Postal / Zip Code

Email*

example@example.com

Mobile Number*

Phone Number*

Work Number

Emergency Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Name of deceased spouse or partner:*

Date of spouse's or partner's death:*

Cause of death:*

Length of marriage / relationship:*

Are you currently employed?*

YesNoOther

If yes, occupation or tell us more:

Are you have children?*

YesNo

If yes, what are their ages?

On a scale of 1-10, how would you rate your current level of grief? (1 being low, 10 being high)*

What are your main challenges in coping with your loss? (Check all that apply)*

Have you experienced any of the following since your spouse's or partner's death? Check all that apply.*

Are you currently receiving any professional support (i.e., individual therapy, medication)?*

YesNo

If yes, please specify:

Have you participated in a grief support group before?*

YesNo

If yes, please specify:

What do you hope to gain from participating in this support group?*

Do you have any concerns about participating in a group setting?*

Are you able to commit to attending weekly session for 5 weeks?*

YesNo

Do you have any special needs or accommodations we should be aware of?*

Do you have any medical conditions we should be aware of?*

What else would you like us to know about you or your grief experience?

I, [participant as named earlier], agree that I will keep confidential the personal information of other group participants taking part in this informal program facilitated by Tamelynda Lux as defined below. For the opportunity to attend this grief group I agree to strictly comply with each of the terms and conditions of this agreement.

1. Confidential Information.

1.1 Definition of Confidential Information. “Confidential Information” means all of the following, whether embodied in intangible form or tangible form:

1.1.1 Confidential business and/or personal information (meaning information which is not generally known to the public or readily ascertainable by proper means by others) about any members, their associates, agents and employees, and all other persons, firms, corporations, associations, partnerships, predecessors, successors in interest, parents, children, subsidiaries, affiliates, or entities having any legal relationship to them (all collectively “Related Parties”); Also personal information” refers to information that may be used to determine the identity of another group member such as the name of a group member, the name of other family members, addresses, or phone number, circumstances of death or any other information.

1.1.2 Private and confidential matters concerning any of the Related Parties, meaning information which is not generally known to the public or readily ascertainable by proper means by others, including without limitation addresses, telephone numbers, contact information, business and plans, designs, financial information, financial information, professional relationships, plans;

1.1.3 Proprietary business information and/or Trade Secrets (“Secrets” means information held in confidence and which has economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by others) of all Related Parties;

1.1.4 This Agreement and its terms.

1.2 Group Member Agreement Not to Disclose or Use Confidential Information. Member acknowledges and agrees that Confidential Information is private and confidential, and that any member has a reasonable expectation of privacy concerning that Confidential Information. Without a members’ advance express written consent, member shall not directly or indirectly, verbally or otherwise, either during or after the group get together, publish, disseminate or disclose (“disclosure”) any Confidential Information to any person, firm or entity whatsoever, including but not limited to family members, friends, associates, journalists, media organizations, newspapers, periodicals, magazines, publications, television stations, radio stations, publishers, databases and any other enterprise involved in the print, wire, internet or electronic media (all collectively “Third Parties”). Without limiting the foregoing, member shall not give or participate in any interviews or write or prepare, or assist in the preparation of, or be a source for, any books, memoirs, articles, programs, or other oral or written communications, disclosing or referring, directly or indirectly, to Confidential Information. In the event of any breach of this provision by any member, members’ copyright in any such unauthorized book, memoir, or other materials described in this provision shall be deemed automatically and immediately transferred by unauthorized member to group member that information pertains to.

This Agreement is to be construed pursuant to the laws of the province of Ontario, Canada. You acknowledge that receiving any information prior to or at or after any meeting, or conversation before, after or at any formal or informal gathering will also be kept strictly confidential and covered in this agreement.

I have read and fully understand the information provided above about the risks and benefits of any grief group work. I understand that if I breach this agreement, I will be subject to all legal consequences.

I have read and fully understand the information provided above about the risks and benefits of any grief group work. I understand that if I breach this agreement, I will be subject to all legal consequences. *

I understand that this information will be kept confidential and used only for the purposes of the grief support group. I agree to participate in the group and abide by its guidelines.*

Thank you for completing the registration form.

I will be in touch with you within 48 hours of receiving your registration to schedule a brief conversation (20 minutes).

Sincerely,

Tamelynda Lux, Certified Coach and Grief Educator

Tamelynda Lux, Certified Life Coach and Grief Educator

Registration Form

Loss Information

Current Situation

Grief Experience

Group Participation

Health Information

Additional Information

Consent