SOSL Support Group - Intake Form

Participant Interest Form
Thank you for your interest in the Survivors of Suicide Loss Support Group! We recognize that reaching out after the loss of a loved one can be difficult. This form helps us ensure the group is a good fit for your needs and allows us to contact you to discuss the group before your first meeting.

Please note: Completing this form does not automatically enroll you in the group. The clinician will contact you to schedule a brief phone conversation to answer your questions, review group expectations, and determine whether the group is appropriate for your current needs.

Personal Information
Name:

First NameLast Name
Preferred Name:
So we can understand the best way to address you, would you like to add your pronouns?
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Are you a military veteran?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Preferred Contact Method:
May we leave a voicemail?
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.

Group Expectations & Understanding

Before participating in the group, we ask that you review the following statements. These expectations help create a safe, respectful, and supportive environment for everyone. Please check each box below to confirm that you have read and understand them.
I understand that this is a peer support group. It is not therapy, a therapeutic group, or a substitute for individual counseling or crisis services.
I agree to respect the privacy and confidentiality of other group members and understand that what is shared in the group should remain private.
I understand that completing this form does not guarantee participation in the group.
I understand that a CareFirstNY clinician will contact me to answer questions, discuss the group, and talk with me about whether it is a good fit for my current needs.

Participant Interest Form