Program Registration Form

Name

Preferred Pronoun

Birthday

Message

Street Address

City

Postal Code

Phone

Preferred Method of Communication

Phone Email

Emergency Contact: (include phone number and name)

Program you are registering for?

Name of deceased loved one:

Relationship:

Date of death:

Have you received formal bereavement counselling and/or support previously? If yes please specify.

Yes No

Specify

What are you hoping for by participating in this program?

In providing the safest, healthiest and most comfortable support experience for you, please share with us any pertinent physical or mental health issues you are or have been treated for:

Is there anything else you feel would be helpful to share with us?

If you are registering a child or teen, please fill out below:

Relationshipo to the Child / Teen

Are you the primary caregiver?

Yes No

Age of child/teen:

What is the child/teen’s understanding of the death:

If there was a funeral/celebration of life etc where they involved. If so how?

Has support from the NHCH Care Provider been discussed? Please specify

Please tell us a little about your child/teen that will help us in providing optimal support: (ie Learning challenges? Behavior challenges? Medications? Likes, dislikes etc)

I consent to bereavement support from the Norfolk Haldimand Community Hospice. I understand that if the Bereavement Care Provider identifies my child/teen as needing support beyond the scope of the NHCH I will be informed and support at that time will be referred elsewhere. I understand if the Bereavement Care Provider becomes aware of abuse - physical or emotional of this child/teen, it would need to be reported immediately to the authorities. I understand that the Bereavement Care Provider will keep me informed regularly of my child/teens progress.

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