Pet Grief and Bereavement
Participant Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
About Your Pet
Pet's Name
*
First Name
Last Name
Type of Pet:
Ex: Cat, Dog, Bird, Reptile etc...
Date of Loss:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How long were they a part of your life?:
Your Grief
1. What brings you to the support group?
2. What are you hoping to gain from the group?
3. Is there anything you would like the facilitator to know about your loss or support needs?
Group Agreement
Please check each box:
I understand this is a support group and not individual therapy.
I agree to respect the privacy and experiences of other group members.
I understand that confidentiality is encouraged but cannot be guaranteed in a group setting.
I understand that participation and sharing are voluntary.
Preferred Contact Method:
Email
Phone
Either
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: