Registration Form for Project Christine

Registration Form for Project Christine

Project Christine is a program hosted in partnership between the Sophia Ann Foundation and Frederick Health Hospice, providing grief counseling for parents and families who have lost an infant or child (under age 18). This group includes separate support groups for adults and surviving siblings (grades K-12) and includes dinner.
Your First Name
Your Last Name
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Can we text the number listed above?
Please SELECT ALL dates you wish to register for (you can register for more later if you only want to register for one right now)
Please List Any Children (under 18) who will be attending. Please list their age as well.
Please provide the name of your loved infant/child who passed and when they passed.
Is there any other details you want the counselor(s) to know about your loss prior to the meeting?
What do you hope to get out of Project Christine?
Please list any Food Allergies for Anyone Attending
Confidentiality Agreement
Policy of Confidentiality

Bereaved persons that are served by Frederick Health Hospice understand that the discussion of their bereavement care remains confidential within the Hospice team, with the following exceptions:

1)      Court-ordered subpoenas

2)      Information assessed in which there is clear and imminent danger to the bereaved or to other people*

3)      Known or suspected child abuse or neglect*

4)      Known or suspected abuse, neglect, or exploitation of a vulnerable adult*

*These exceptions require immediate reporting to a proper care provider or agency that can ensure the safety and appropriate interventions for all concerned.

I understand that the information discussed by myself and other participants during group sessions is confidential information.

I understand the policy statement of Frederick Health Hospice’s Bereavement Program regarding confidentiality and mandated reporting.
Signature
Printed Name
Date of Signature

MonthDayYear
Date
How did you hear about Project Christine?
Should be Empty: