Caregiver’s Support Group Registration Form

Caregiver’s Support Group Registration Form

Register to join HOC Caregiver's Peer Support Group. Please provide your information below. For questions, contact Kim Mendoza (kmendoza@heartofthecumberland.org / 931-525-2600).
What is a Peer Support Group? A peer support group is simply a forum for mutual acceptance, understanding, and self-discovery through communication with peers who have been in similar situations. If a group member is looking for specific advice or counseling, they are advised to contact a licensed practitioner or professional. Our volunteer lead peer support groups are a safe place to find encouragement and support.
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City*
State*
Zip Code*
Emergency Contact Name*
Emergency Contact Phone*
Please enter a valid phone number.
Caregiver Information

The following questions help us understand your situation and responsibilities.
Person Being Cared For*
Age of Person*
Relationship to You*
How long has this person been in your care?*
What is the diagnosis or condition for the provided care?*
How did you hear about Heart of the Cumberland?*
Our Privacy / Confidentiality Policy

Heart of the Cumberland, through its dedicated volunteers, staff, and boards makes every effort to keep things shared by participants confidential and encourages group participants to do the same. Information given 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 will be given to group facilitators. Our confidentiality policy will be strictly maintained except, but not limited to, the following: Participant Consent, Suicidal Expression, 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 Courts.
I have read, understand and agree to abide by the confidentiality policy and the peer group definition outlined on this form.*

I agree
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Caregiver’s Support Group Registration Form

Caregiver Information

Our Privacy / Confidentiality Policy