Registration Form

Aseshate:ka'te Grief Services
Registration Form

For new grief recovery groups and one on one sessions.
Name *

First Name Last Name
Birth Date

Month Day Year
Phone Number *

Area Code Phone Number
Address
Or district of Akwesasne you reside in
Name of Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Please explain below, the reason that you are accessing services at this time? *
Have you 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:
Service Requested *
There are many losses we all face in our lifetime. Please check any losses that you have experienced from the following listed below

Death of a loved one Miscarriage/stillborn Absent Parent Jail/Prison Child abuse End of Addictions Sexual abuse/assault Been in Foster Care Break up/Divorce Loss of Friends Parents divorced Loss of Health Loss of Trust Loss of Language Loss of Culture Loss of Identity Job Loss Loss of control Loss of Home Victim/Witness of DV You, your parent or grand parent attended Residential School
If you have checked any of the above losses, you have experienced grief. How has grief affected you in the following areas? Please explain.
Mental Health Issues *
Physical Health Issues *
Emotional Health Issues *
Spiritual Health Issues *
Relationships *
Work/School *
How do you normally cope with grief issues? *
Do you currently see anyone for help?

Yes No
If yes, Where do you access services?
Do you feel you have someone to talk to when you need help?

Yes No
If you answered yes, check who you feel is in your support system: *

Mother Father Step Parent Sibling Friend Spouse Grandparent Aunt Uncle Cousin Teacher Counselor Spiritual Advisor Social Worker Others not listed
Do you feel you need to see someone right now for your grief issues?

Yes No
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

Yes No
Are you comfortable with your level of reading/writing/comprehension?

Yes No
Would you prefer an audio cd of the handbook used in group?

Yes No
Do you have any questions or concerns about entering this group?
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 this 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 leave the group 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 group. If I am unable to overcome these issues, I agree to seek out other help that is available in the community.
I agree to the above participation agreement.
How did you hear about Aseshate:ka'te Grief Services?
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Aseshate:ka'te Grief Services

Registration Form