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?
Mission Valley
Escondido
Either Mission Valley or Escondido
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