Registration and Consent to Participate in COJ's Virtual Bereavement Support Groups

RSVP for Starting the Journey: Understanding Grief Before Support Group

Please complete this form to let us know you are attending the next session! We will send you a reminder email closer to the session date. If you have any questions, please call our office at 513-870-9108. Thank you!
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState (2 Letter Abbreviation)

Zip CodeCountry
Gender of Participant
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Tell us about your loved one.
Name
Date of Birth

MonthDayYear
Date
Date of Death

MonthDayYear
Date
The person who died is my:*

ChildSpouseMotherFatherGrandparentBrotherSisterAuntUncleCousinFriendPartnerGrandchildOther
Type of death/loss:*

IllnessAccidentSuicideMurderIncarcerationDeportationOverdoseOther
Additional losses you would like to share with us:
How did you hear about Companions on a Journey?*

ReferralSocial MediaWebsite
If by referral, please list the name of the person or organization who provided the referral.
By registering with Companions on a Journey Grief Support, you will be added to our email communications. You may unsubscribe to these communications at any time.
Should be Empty:

RSVP for Starting the Journey: Understanding Grief Before Support Group