Grief Journey - Registration

Grief Journey - Registration

Thank you for your interest in the Grief Journey support group at Luciak Counselling. This short registration form collects the information we need to register you for the group and help the facilitator prepare for participants. All information shared is kept confidential.
Full Name*

First NameLast Name
Please tell us a bit about your grief. Who has passed and when? *
Approximate dates are fine! This information will only be shared with Iska Hollman (Therapist / Group Facilitator).
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Insurance / Direct Billing / Payment*
Health Insurance Provider
If you wish to use health Insurance, please upload a photo of your insurance card.

Cancelof
I understand there is a one-time non-refundable payment of $55 (via credit card) to join the group. This cost covers basic administrative functions of the group.I understand that each group session costs $55. Some direct billing is available however we do not guarantee insurance payouts or coverage. Amounts not covered by insurance will be charged to the credit card on file on the group session day and a receipt provided via email.I will do my best to arrive 10-15min prior to the group session to ensure the group begins on time for everyone.There are 7 weekly sessions planned. To best support yourself and the group, please do your best to attend each one. We require 24 hours notice for cancellation.All participants are expected to maintain the confidentiality of other group members. This means that any personal information, experiences, or identifying details shared during group sessions must not be disclosed outside the group. Although the group facilitator is bound by professional confidentiality standards, confidentiality cannot be guaranteed among group participants. By registering for this group, you acknowledge and agree to respect the privacy of all members.
Signature*

Clear
Ready to join?

To complete registration, a credit card is required. A one-time administrative fee of $55 will be charged upon registration. Your card will also be kept on file and may be charged only if insurance direct billing does not cover the cost of a group session on the date it takes place.
Should be Empty:

Grief Journey - Registration

Ready to join?