Registration is required for all our Grief Support Groups. If you need more information, please call Pikes Peak Hospice & Palliative Care Center for Grief and Loss at 719.633.3400 (option 5). Or email us at BereavementTeam@pikespeakhospice.org. HiddenDate MM slash DD slash YYYY Grief Support Group OptionsType of Support Group/Event*Please select the support group type you wish to register for: Adult Grief Support Children's Grief Support (Note: no children's groups are being offered at this time.) Support Group Fees We care for our community as they endure losses that may not include someone on our hospice service. We are here for you too. Individual Counseling sessions and grief support groups are available to our Community Clients for a fee. The current fee for adults is $60 ($10 per session). There is no fee for any of our children's programs. A sliding fee scale is available based on ones ability to pay. Veteran and active military discounts are available. Please contact us for more information at BereavementTeam@PikesPeakHospice.org or call 719.633.3400 option 5. Participant Type* I am a Community Member seeking counseling (not a friend or family member of Pikes Peak Hospice patient) I am a Friend or Family Member of a Pikes Peak Hospice patient Name of Hospice Patient* Support Group SessionAdult Support Groups for CommunityPlease select the session you wish to register for. The price is $60. If you wish to register for more than one, please submit a registration form for each session. Price: Adult Support Group Choices for Community* MONDAY SESSION 1: March 11th - April 15th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 1: March 14th - April 18th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 2: May 6th - June 16th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 2: May 9th - June 13th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 3: July 8th - August 12th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 3: July 11th - August 15th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 4: September 9th - October 14th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 4: September 12th - October 17th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 5: November 4th - December 9th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 5: November 7th - December 12th, 10:00 a.m. - 12:00 p.m. Adult Support Groups for Family/FriendsPlease select the session you wish to register for. If you wish to register for more than one, please submit a registration form for each session. MONDAY SESSION 1: March 11th - April 15th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 1: March 14th - April 18th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 2: May 6th - June 16th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 2: May 9th - June 13th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 3: July 8th - August 12th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 3: July 11th - August 15th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 4: September 9th - October 14th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 4: September 12th - October 17th, 10:00 a.m. - 12:00 p.m. MONDAY SESSION 5: November 4th - December 9th, 3:00 p.m. - 5:00 p.m. THURSDAY SESSION 5: November 7th - December 12th, 10:00 a.m. - 12:00 p.m. Contact InformationContact Name* First Last Contact Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Primary Phone*Please indicate if this is a mobile, home or work number. Mobile Home Work Contact Email* Contact Date of Birth MM slash DD slash YYYY Additional Attendees?Please list any additional people that will be joining you. Children's Group InformationChildren's Support Groups/EventsChildren's Support Groups are offered from 4:00 p.m. - 5:30 p.m. the 2nd and 4th Thursday of each month. Please indicate below the date(s) you plan on attending. Child's Name* First Last Child's Age*Child's Parent/Guardian Name* First Last Child's Parent/Guardian Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Guardian's Relationship to Child* Child's Parent/Guardian Email* Child's Parent/Guardian Primary Phone*Please indicate if this is a mobile, home or work number. Mobile Home Work Best Way to Reach Parent/Guardian?What is the best way to reach you? Primary Phone (from above) Email Child's Behaviours/Developmental InformationPlease indicate any concerns that are worth noting such as ADHD, being on the on the spectrum, developmental age different from actual age, etc.Additional Attendees?Please list any additional people that will be joining, their phone number, and their relationship to the child. Special Needs?Please list any special needs your child/children (or adult accompanying them) have.HiddenCommon InfoConcerns about Grief/LossPlease list any concerns you have about the grief/loss process:Allergies/Medical Conditions?Please list any allergies or medical conditions that we should be aware of. Please be aware that our staff is unable to dispense medications of any kind.Zoo Camp InformationT-shirt Size Small Medium Large Volunteer BuddyDo we need to assign a Volunteer buddy for the child? Yes No Information about the DeceasedPlease tell us a bit more about your loved one so we can best support you.Name of deceased* First Last Relationship to deceased* Date of death* MM slash DD slash YYYY Place of death Age at death* Cause of death Interested in Other Grief Services?Other Grief Counseling and Grief Support GroupsI am interested in knowing more about or attending (please check all that apply) : Men's Adult Grief Support Group Women's Adult Grief Support Group Individual Grief Counseling Sessions Billing InformationBilling Name* First Last Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Billing Email* Billing PhoneTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name ConsentConsent* I consent to allow Pikes Peak Hospice & Palliative Care to collect the information on this form. *Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.NameThis field is for validation purposes and should be left unchanged.
