Registration Form

Name*

First NameLast Name

Birth Date

MonthDayYear

Phone Number*

Area CodePhone Number

Address

Or district of Akwesasne you reside in

Name of Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Please explain below, the reason that you are accessing services at this time? *

Have you recently experienced a death of a loved one or a traumatic event that you are having trouble coping with? If so, can you choose below how long ago this was:

There are many losses we all face in our lifetime. Please check any losses that you have experienced from the following listed below

If you have checked any of the above losses, you have experienced grief. How has grief affected you in the following areas? Please explain.

How has grief affected your Mental Health?*

How has grief affected your Physical Health?*

How has grief affected your Emotional Health?*

How has grief affected your Spiritual Health?*

How has grief affected your relationships?*

How has grief affected your work and/or school?*

How do you normally cope with grief issues? *

Do you currently see anyone for help?

YesNo

If yes, Where do you access services?

Are you currently on any prescription medications for mental health issues?

YesNo

Do you feel you have someone to talk to when you need help?

YesNo

If you answered yes, check who you feel is in your support system:*

Do you feel you need to see someone right now for your grief issues?

YesNo

What is your religious background?

Do you feel comfortable with cultural components added to the group process? For example: thanksgiving address, smudging, tobacco burning, traditional medicines

YesNo

Do you have any questions or concerns about accessing services at this time?

Please list below days of the week and times that work for you, including weekends. Please know that group sessions are 2-3 hours in duration, once per week. Evening groups begin at 6pm and there is no food provided at group. Weekend groups are usually during the daytime only.

E-mail*

Participation Agreement

I am willing to attend the Aseshate:ka’te Grief Group of my own free will and agree to participate in my own healing for my own benefit. I understand the F.I.R.E. process is emotionally hard, but I am willing to attempt to overcome my fears as I strive to heal myself and my family. I also agree to seek out extra help if my emotions become overwhelming for me.

I understand that the group I participate in is a confidential group and I will not disclose who is in the group to anyone outside the group. I also understand that if I feel I cannot participate because of conflict of interest with someone else in the group, I will let the facilitator know and will join a different group as it becomes available.

I am also aware that I may discontinue grief services at any time if I feel it isn’t right for me. If my emotions become overwhelming for me, I agree to discuss these issues with the facilitator before leaving the session. If I am unable to overcome these issues, I agree to seek out other help that is available in the community.

I also understand and agree to be free of alcohol or drugs (including cannabis) before and during group.

I agree to the above participation agreement.

How did you hear about Aseshate:ka'te Grief Services?