Bereavement Support Intake Form
*Indicates required question
Email
*
example@example.com
Welcome
Stedman Community Hospice offers diverse and accessible bereavement support programs to Brant, Haldimand, and Norfolk counties free of charge. If you are interested in participating in one of our support groups, we kindly ask that you complete the following intake form. The information you provide will help us better support you through your grief journey. Please know that all information provided will be kept strictly confidential.
I consent to sharing the following information with the Stedman Community Hospice Supportive Care Team
*
Yes, I consent
No, I do not consent
Contact Information
Name
*
First Name
Last Name
Phone Number (home)
*
Please enter a valid phone number.
Phone Number (cell)
Please enter a valid phone number.
Preferred method of contact
*
Home phone
Cell phone
Email
Date of Birth
*
-
Month
-
Day
Year
Date
Pronouns (she/her, he/him, they/them etc.)
*
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Bereavement Information
Which bereavement support group are you interested in at this time?
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Coffee & Connection Support Gathering
Together In Grief Support Group
Partner/Spousal Loss Support Group
Mixed Loss Support Group
Young Adults Mixed Loss Support Group (next session - Fall 2025)
2SLGBTQIA+ Grief Support Group
Have you ever participated in a bereavement support group/program?
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Yes, at Stedman Community Hospice
Yes, but not at Stedman Community Hospice
No
How did you hear about the bereavement support service offered at Stedman Community Hospice?
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My loved one died at Stedman Community Hospice
From a relative/friend
From a health care professional
From the Stedman Community Hospice Website
From the Stedman Community Hospice Facebook/Instagram Page
Other
Name of deceased
*
Deceased's date of birth
*
-
Month
-
Day
Year
Date
Date of death
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-
Month
-
Day
Year
Date
The deceased was my...
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Spouse
Parent
Child
Sibling
Grandparent
Friend
Other
Did the deceased receive palliative care?
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Yes
No
If yes, where did the deceased receive palliative care?
At Stedman Community Hospice
At home
Other
If no, where did the deceased die?
Hospital
Home
Other
The loss was...
*
Expected
Sudden/unexpected
If this loss was sudden/unexpected, what was the manner of death?
Illness
Accident
Suicide
Homicide
Overdose
Other
How do you feel you are coping with the loss? On a scale of 1-10, select the number that best describes how well you are coping today.
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Not
1
2
3
4
5
6
7
8
9
Coping well
10
1 is Not , 10 is Coping well
What are your current coping mechanims/strategies?
*
Are you currently or have you ever seen a mental health professional?
*
Yes
No
If yes, please elaborate:
Are you currently experiencing or have you ever experienced any other losses (e.g., another death, breakup/divorce, job loss, financial hardship, move, etc.). If yes, please describe:
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Is there any other information you would like the Supportive Care Team to know?
Submit
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