COUPLES APPLICATION

If you would like to register for the in-person or virtual group, please complete this application and someone will get back to you soon.

Partner A Name:

First

Last

Partner A Phone:

Partner A Email

Partner B Name:

First

Last

Partner B Phone:

Partner B Email:

Tell us about yourselves:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

How long have you lived in the area?

Partner A date of birth:

Partner B date of birth:

Tell us about your family.

How many people live with you?

Where is your extended family located?

Are you close to them?

Tell us about your loved one that died.

Their name:

First

Last

Their age:

Their date of death:

How did they die?

How did you hear about it?

What else would you like us to know about your loved one?

What have you found to be supportive while you have been grieving?

How did you hear about the Companioning Project Grief Group?

B What about

Is there anything else you would like us to know?

Finally, when do you prefer to meet?

WE ARE THANKFUL TO OUR FRIENDS AND PARTNERSHIPS: