Children's Peer-Based Grief Support Group Interest Form

Thank you for your interest in the Children's Bereavement Program at The Elizabeth Hospice.

The children's peer-based grief support groups are offered to children and teens ages 3-17 years old who have experienced the death of a loved one. Groups are offered bi-weekly throughout the academic year (October-May). Each group features a concurrent adult/caregiver group and is offered at no-cost.

Please complete this group interest form so that we can contact you when applications are available for the next group season.
1.Child(ren)'s Full Name (s)(Required.)
2.Child(ren)'s Age(s)(Required.)
3.Caregiver's Full Name(Required.)
4.Caregiver's Phone Number(Required.)
5.Caregiver's Email Address(Required.)
6.Which Children's Bereavement Center is your family interested in attending?
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