Journeying Through Grief

Questionnaire & Registration (or Waitlist)

Select Class Date:
October 31st to December 19th — 1:30 - 3:30 pm

This 8-week program is suitable for those who have experienced the loss of a loved one and want to feel a sense of understanding with others going through similar experiences.

This class may be more difficult for you if you have a pre-existing mental health diagnosis with current symptoms and/or trauma.

Questions

Your answers will help us understand whether this program would be the best fit for you.

1. Please indicate your type of loss:
Divorce or other relationshipPetLoved oneJob lossGrief due to a moveOther*
*Indicate Other:

When did your loss occur?

2. What have you been doing to cope and care for yourself? (E.g. taking baths, eating well, reaching out to others to talk, allowing yourself to cry, exercising, still participating in pleasurable activities).

3. Are you coping by numbing your pain with any substances?

What substance(s):

How much:

How often:

4. Are you having thoughts of suicide or self-harm?
NoYes

In what ways:

How often do you experience this?

5. Do you have a support person who is helping you now and would be available during the group?(i.e.,friend, counsellor, clergy)

6. How comfortable are you in a group setting? Rate yourself from 1 to 10 (1 being not comfortable at all, and 10 being very comfortable).

7. What are hoping to get out of this class?

If you are in immediate distress or feeling suicidal, please call 9-1-1 NOW.

24-Hour Distress Line: 780-482-HELP (780-482-4357)

Alberta Mental Health Helpline: 1-877-303-2642

Contact information for Registration

First Name *

Last Name *

Email Contact *

Telephone/Cell *

Postal Code (for client validation)

Date of Birth (yyyy-mm-dd) *

Gender
MaleFemaleIdentifies as OtherDecline to indicate

Provider Information

Your Family Doctor * (Please type the name of your Family Doctor (or type n/a if you don't have a doctor)

Your Doctor's Clinic * (Please type the name of your clinic (or type n/a if you don't have one)

I allow PCN to contact my medical provider with my information

I allow PCN to contact me electronically

* Denotes required field.

Please be aware that this form is for a registration REQUEST only. Once you have completed and submitted your questionnaire, a scheduling coordinator will contact you to confirm your registration or get more details from you.