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.

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* 1. Child(ren)'s Full Name (s)

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* 2. Child(ren)'s Age(s)

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* 3. Caregiver's Full Name

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* 4. Caregiver's Phone Number

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* 5. Caregiver's Email Address

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* 6. Which Children's Bereavement Center is your family interested in attending?

Mission Valley

Escondido

Either Mission Valley or Escondido