Transcending Grief Group and Gathering Night groups

Transcending Grief Groups Registration Form

Please complete the form below to register for a Transcending Grief group. You will be contacted to confirm the group(s) will be taking place (we must have four (4) registrants). Dinner is provided from 6:00 p.m. - 6:30 p.m.
Full Name *

Prefix First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
May we call you and or leave a message on this number? *
E-mail *
May we contact you via this email address? *
Name of Insured (who carries/has insurance) *
Name of Insurance Company *
Insurance: ID Number *
Insurance: Group Number *
Insurance: Phone Number *
Birth Date (of insured for insurance submission)

Month Day Year
Birth Date (of person requesting Group counseling service)

Month Day Year
What is the relationship of your loss to you: *
Cause of death? *
When did your loss occur? *

Month Day Year
Food allergies (List all that apply). Dinner is from 6:00-6:30 p.m. prior to each group. *
Select all Transcending Loss groups (required to have attended a group at Kelly's Grief Center) and or Gathering/Craft nights (open to all) you which to attend.

January 29, 2020 - 6:00 p.m. - 8:00 p.m. Transcending Group February 26, 2020 - 6:00 p.m. - 8:00 p.m. Transcending Group March 25, 2020 - 6:00 p.m. - 8:00 p.m. Transcending Group April 22, 2020 - 6:00 p.m. - 8:00 p.m. Transcending Group
Cost is $20.00 per person
Please share which group you have attended previously at Kelly's Grief Center (required for Transcending Groups): *
For more information call Kelly's Grief Center at 330.593.5959 (please leave a message) or email: kellysgriefctr@gmail.com
Should be Empty:

Transcending Grief Groups Registration Form