New Group Member Registration

New Group Member Registration

Welcome! We’re honored to walk with you through this season. Please complete this form so our team can help place you in the group that will best support you on your healing journey.
Contact Information
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Emergency Contact:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group Member Information
Name of your loved one:*
Age of your loved one:*
Date of loss:*

MonthDayYear
Date
Type of loss:*
Session Registration

Please select the group you are registering for.
Session:
Time:*

11:00AM start time6:00PM start time
Group:*
Our focus groups meet in the spring and the fall. If you are joining during the summer or winter, select 'General.' If you’re unsure, select ‘Other’ and a member of our team will contact you to discuss the groups and help with placement.
Please list any children you are bringing to childcare or a group:
How did you hear about Heart of the Cumberland?*
About
What to Expect

Groups meet once a week for about an hour, depending on the group and session. Our groups are free of charge and designed for your benefit—the more you attend, the more you’ll gain. Average group sizes are under 10 participants, creating a small, intimate space where you can feel safe to share and connect. Childcare is available for select sessions—please see the program schedule for details.
Privacy and Confidentiality Policy

Heart of the Cumberland, through its dedicated volunteers, staff, and board, makes every effort to keep what is shared by participants confidential and encourages group participants to do the same. Information provided to Heart of the Cumberland will only be used for the express purpose for which it is gathered. All files are and will remain the exclusive property of Heart of the Cumberland. Participant contact information is securely maintained and is shared only with group facilitators for program-related purposes.

Our confidentiality policy will be strictly maintained except in the following circumstances (including, but not limited to):
- Suicidal expressions
- Suspected physical, mental, or sexual abuse, which by law must be reported (Tennessee Code Annotated 37-1-403(i)(1))
- Suspected drug or alcohol use/abuse by a child
- Mandates of the court
I have read, understand, and agree to abide by the confidentiality policy and peer group definition outlined on this form.*

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New Group Member Registration

Contact Information

Group Member Information

Session Registration

About