Support Group Registration

Registration is required for all our Grief Support Groups and Special Events. 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.

NOTE: The form below is for registering for our ongoing Support Groups.
Click here to register for one of our Special Events.

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Date
MM slash DD slash YYYY
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Grief Support Group Options
Type 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 Session
Adult Support Groups for Community
Please 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: November 4th – December 9th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 1: October 31st – December 12th, 10:00 a.m. - 12:00 p.m.
- MONDAY SESSION 2: January 6th – February 17th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 2: January 16th – February 20th, 10:00 a.m. - 12:00 p.m.
- MONDAY SESSION 3: March 10th – April 14th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 3: March 13th – April 17th, 10:00 a.m. - 12:00 p.m.
Adult Support Groups for Family/Friends
Please 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: November 4th – December 9th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 1: October 31st – December 12th, 10:00 a.m. - 12:00 p.m.
- MONDAY SESSION 2: January 6th – February 17th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 2: January 16th – February 20th, 10:00 a.m. - 12:00 p.m.
- MONDAY SESSION 3: March 10th – April 14th, 3:00 p.m. - 5:00 p.m.
- THURSDAY SESSION 3: March 13th – April 17th, 10:00 a.m. - 12:00 p.m.
Contact Information
Contact Name*
First Last
Contact Address*
Street Address Address Line 2 City State 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 Information
Children's Support Groups/Events
Children'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 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 Information
Please 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.
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Common Info
Concerns about Grief/Loss
Please 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 Information
T-shirt Size
- Small
- Medium
- Large
Volunteer Buddy
Do we need to assign a Volunteer buddy for the child?
- Yes
- No
Information about the Deceased
Please 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 Groups
I 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 Information
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Email*
Billing Phone
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Consent
Consent*
- 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.
Name
This field is for validation purposes and should be left unchanged.

Registration is required for all our Grief Support Groups and Special Events. 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.

Grief Support Group Options

Support Group Fees

Support Group Session

Contact Information

Children's Group Information

Common Info

Zoo Camp Information

Information about the Deceased

Interested in Other Grief Services?

Billing Information

Consent