Support Group and Camp Kelly Registration Form

Kelly's Grief Center Support Group and Camp Kelly Pre-Registration Form

Please complete the form below to register for a group. You will be contacted within two weeks of the group starting date by a counselor from Kelly's Grief Center. No one will be turned away from attending group with the inability to pay. Please contact Kelly's Grief Center with any questions.
If client is minor, please provide name of Parent/Guardian completing form.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
May we call you and or leave a message on this number?*
E-mail*
May we contact you via this email address?*
Group interested in attending (see descriptions below):*
What is the relationship of your loss to you:*
Cause of death?*
Age of your loved one at time of death?*
When did your loss occur?*

MonthDayYear
Birth Date (of person requesting group counseling services)*

MonthDayYear
Have you attended a support group before*
Please share where, if you have attended a grief group previously:
How did you hear about Kelly's Grief Center? *
For more information call Kelly's Grief Center at 330.593.5959 (please leave a message) or email: phyllis@kellysgriefcenter.org
Please note groups will run when there are a minimum of five (5) or maximum of ten (10) registered. Other groups may be added if minimum registration is met.

Groups will run twice a year and Camp Kelly anually.
- All Groups begin at 6:30 p.m. and end at 8:30 p.m.
- Group members are encouraged to attend all group meetings. (This promotes a cohesive group.)
- Camp Kelly is hosted during summer months. Please refer to website for dates. Minumum number of campers is ten (10) maximum twenty (20).
All Groups and Camp Kelly will take place at:

Kelly's Grief Center
- 2275 State Route 59
- Kent, OH 44240
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Group descriptions that run 10 weeks:
- Accidental Overdose
  - For those who have lost a loved one to an Accidental Overdose
- Murder Loss
  - For those who have lost a loved one to Murder/Homicide
- Suicide Loss
  - For those who have lost a loved one to Suicide
Groups descriptions that run 8 weeks:
- Perinatal/Infant Loss
  - For grieving adults who have had a miscarriage, stillbirth, or have lost a child under the age of 2
- General Loss
  - For grieving adults for various losses (may break down to specific groups)
- Parent Loss
  - For those 18 years and older who have lost a parent (may combine into a general loss group)
- Spouse Loss
  - For those who have lost a spouse or significant other (may combine into a general loss group)
Additional Comments:
This is a fill in the blanks field. Please add appropriate blank fields and text.
Should be Empty:

Kelly's Grief Center Support Group and Camp Kelly Pre-Registration Form