Pet Loss Support Group Enrollment Form
CCC is providing Pet Loss Grief group for those who have experienced a loss of a beloved pet. This is not a drop-in support group but one that allows members to develop a trusting relationship with one another throughout the course through continued attendance.
Legal Name
*
First Name
Last Name
Name you go by (if different)
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Must be 18 or older to enroll in services.
Pronouns
*
she/her, he/him, they/their, etc.
Email
example@example.com
Phone Number:
*
Example: 555-555-5555
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 (where you currently reside)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please tell us briefly about the loss you have experienced.
*
What month and year did you experience this loss? (approximate if you are not sure)
*
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Mental Health Information
This section allows us to learn a little more about you and your experiences with counseling and helps us make sure that this group is the right fit for where you are at in your healing journey.
Are you currently enrolled in individual therapy?
*
Yes
No
No, but I am interested in help getting connected to that service.
Where do you currently receive counseling? With whom?
Have you EVER been hospitalized for mental health reasons?
*
Yes
No
Please tell us more about what happened. When was this? What was the outcome?
Have you EVER had any serious thoughts of or past attempts to die by suicide?
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No
Thoughts only
Thoughts and plans
Thoughts, plans, and past attempt(s)
Please tell us more about these thoughts? What are/were they like?
Please tell us more about these thoughts and plans.
Please tell us more about your past attempt. When was this? What happened?
Do you CURRENTLY have any thoughts or harming yourself or harming others?
*
No
Yes
Please pause this form and call one of the resources below for immediate support.
We want you to be safe.
Please reach out to one of the supports below if you need someone to talk to 24/7.
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Emergency Information
The Center for Community Counseling is not an emergency or suicide support center. If I need immediate support, I will contact WhiteBird Crisis Line, Lane County Behavioral Health Crisis Line, the National suicide prevention warmline, or 911.
*
I understand the statement above and I am aware of services available to me in case of an emergency.
Emergency Contact
This information is required for enrollment.
In a rare case in which a facilitator becomes concerned about your safety, we will relachout 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
*
First Name
Last Name
Emergency Contact Phone Number:
*
Example: 555-555-5555
Relationship with the contact person
*
i.e. sibling, spouse, friend, parent, etc...
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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 the authorities. You may choose not to answer any question(s).
What is your racial or ethnic background?
What is your gender?
What is your marital or relationship status?
Do you have a Deaf, neurodivergent, chronic illness, or disability identity that you would like to share with us?”
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Household Information
How many people are in your household?
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
Are you a parent? (biological, adopted, or step-children that you provide(d) care for or financially support)
*
Yes
No
How many children 18 and under do you have or provide care for? (biological, adopted, or step-children)
How many adult children do you have?
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Rights and Responsibilities of Group Memebers
Ground Rules of Our Group. (By checking EACH box, you agree to the ground rule)
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Respect of all group members, especially those who have a different view than yours, to build a group that works for everyone.
Members of a group may not use drugs or alcohol before or during group.
Confidentiality- What is said in group stays in group. Do not share anything said in group with non-group members or with group members while outside of the group setting.
Confidentiality - IF the group is online, ensure that you find a confidential space where no one else can hear what is being talked about.
Responsibilities of facilitators (please check all to indicate that you understand and agree to each responsibility.)
*
Facilitators will provide work to provide a safe space for group members to explore subjects that are important to the group.
Facilitators will not share information about you with anyone without a written release unless there is a risk of harm to yourself, someone else, or a risk of child or elder abuse.
Facilitator may be supervised by a mental health professional who will review your case to ensure you are receiving appropriate care. The supervisor is bound by the same laws of confidentiality.
All mental health professionals are mandatory reporters in the state of Oregon. If there is suspicion of current abuse or neglect of a child or a vulnerable adult, your counselor must inform the Department of Human Services with or without your consent.
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In-Person and Online Meeting Information
CCC highly values our client's mental and physical health. Please read the following statement and check each box to denote that you understand and agree to the following:
*
In order to protect the vulnerable members of our community who frequent our facility, masks will be provided and are encouraged in common areas in the center.
If I have suspected or confirmed exposure to Covid-19, I will inform my group facilitator that I am UNABLE TO ATTEND IN-PERSON until I have waited 5-10 days from exposure to test and received a NEGATIVE test result.
If I have confirmed exposure to Covid-19 and have received a positive test result, I WILL NOT RETURN TO IN-PERSON SERVICES until I wait at least 10 days from my positive test result, find that my symptoms are lessening and I am fever-free for at least 48 hours
If I have any other type of illness (cold, flu, etc.) I acknowledge that I WILL NOT RETURN TO IN PERSON SERVICES unti I am fever-free for AT LEAST 48 hours.
If I do not have a fever but I have active cold symptoms and choose to attend in-person services, I will wear a mask to mitigate the spread of illness to other clients and volunteers.
Please read the following and check each box to note your understanding:
*
I understand there may be times that the facilitator can not attend due to illness. In that instance, an email or text will be sent to cancel or notify me of an online option.
If the meeting is online, there will be a link to a HIPAA compliant online platform for the meeting. Other participants and I will ensure that we are in a safe and confidential space to attend the meeting online.
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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.
Please consider the value of this service and your ability to pay per session when choosing your sliding scale fee.
*
$5
$8
$10
$12
$15
$20
$25
$30
$35
$40
Please check the box that best describes how you will pay for sessions.
*
I will pay for sessions by cash or check in person after each session or for the full 4-week amount up front.
I would like to be billed electronically for the full 4-week amount.
I will contact counseling@ccceugene.org to set up a payment plan not listed above.
Is there anything else you would like us to know?
By signing, I testify that the information I provided is correct and that I agree to the terms of this group.
Please use your mouse or track pad to sign your name on the line above.
Submit
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