• Donate
  • Volunteer
  • Access Support
  • Subscribe to Our Newsletter
  • Newsletter Archives
www.countryhospice.org www.countryhospice.org www.countryhospice.org www.countryhospice.org
  • Home
  • About Us
  • End-of-Life Care
  • Compassion In Action
  • Programs & Support
  • Get Involved
  • Support Us

Program Intake Form


Thank you for your interest in the grief and community support programs at the Foothills Country Hospice. Please fill in the following intake form to connect with us.

Are you submitting the intake form on behalf of yourself, or a patient/resident?

Please fill out the form below with your patient or resident's information.

Please fill out your information below.

Please select which of the following best describes the individual's current residence: *
Do you currently live in a retirement community, supportive living, or long-term care location?

Please confirm the individual you're referring is aware of this referral:

We ask that you read the following statement to the individual you're referring:

These programs are part of the work the Foothills Country Hospice is doing to support our community. We would like to contact you in the future to complete a voluntary follow-up survey. This will help us understand if we need to make any changes, as well as help us secure more funding in the future. *
These programs are part of the work the Foothills Country Hospice is doing to support our community. We would like to contact you in the future to complete a voluntary follow-up survey. This will help us understand if we need to make any changes, as well as help us secure more funding in the future. *
Please indicate the preferred mode of contact for follow up:
When was the loss experienced?
When did you experience your loss?
Which of the following best describes the type of loss:
Which of the following best describes your loss?
Participant's Age Group: *
Age Group: *

Program Descriptions

Below are descriptions of our programs. There is no cost to participate and you can refer individuals to as many programs as you would like. Select which programs are of interest at the bottom of the page.

Program Descriptions

Below are descriptions of our programs. There is no cost to participate and you're welcome to select as many programs as you would like. Select which programs are of interest to you at the bottom of the page.

Bereavement Boxes

Bereavement boxes support individuals following the loss of a loved one by providing role specific, physical grief resources, and coping strategies. It can be a tangible way for someone to have access to resources that they use in their own time.

Compassionate Conversations

Compassionate conversations support individuals following the loss of a loved one by offering connection and conversation with a trained bereavement volunteer. This is not a counselling service, but an opportunity to invite supportive and compassionate conversation into the grief journey.

Volunteers will offer up to one hour of conversation per month, and up to 12 months following the loss of a loved one.

Expressive Arts 

Expressive Arts is a group based creative program that provides the opportunity for participants to share alongside others while participating in interactive programming, in a safe and supportive environment. We recommend participants be at least 3 months from the date of their loss before attending group. Our Expressive Arts program is offered quarterly.

Grief Group 

Grief Group is an opportunity for support among others who have similarly experienced a loss. It allows for conversation, compassion, and connection. We recommend participants be at least 3 months from the date of their loss before attending group.

Please note - Anyone new to grief group will be contacted by our Registered Social Worker for a brief assessment to determine which group is the best fit for their needs.

Grief Counselling

Grief counselling with a Registered Social Worker is available to those who may benefit from more personalized supports in their grief experience. These short-term offerings are one hour long and can range from 1-3 sessions. Our social work team will call for a brief assessment prior to booking the first appointment.

Which programs are of interest to your patient/resident? *

Which of the following programs are you interested in? *

What is the best way for this individual to receive their Bereavement Box?Please note: deliveries are typically completed once per week by our volunteers.
Bereavement boxes will be available for pick up from the reception desk at the hospice. If you're in supportive living, and are unable to pick it up, we will arrange for a volunteer to drop it off.Please note that our deliveries are typically completed once per week by our volunteer team.
Was the death expected?
Was the death of your loved one expected?
Which month would the person you're referring like to start participating in the program?
Which month would you like to start participating in the Expressive Arts program?
What is the preferred setting to attend grief group?
What is your preferred setting for attending grief group?
What is the preferred setting to attend grief counselling?
What is your preferred setting for attending grief counselling?

Please provide your contact information below. We will only contact you if we have trouble connecting with the individual you've referred.

Technical Support

If you’re having technical difficulties, or have questions, please don’t hesitate to contact us through grief@countryhospice.org.

If you’re having technical difficulties, or have questions, please don’t hesitate to contact us through grief@countryhospice.org.

Thank you,

WHO WE ARE

About Us

DE&I Statement

Our Team

Careers

Request for Proposals

Community Reports

Contact Us

HOW WE HELP

End-of-Life Care

Programs and Support

Frequently Asked Questions

Resources

GET INVOLVED

Compassion in Action Campaign

Fundraise

Volunteer

Upcoming Events

Corporate Groups

Give Us Feedback

DONATE

Donate Now

Give Monthly

A Gift in Your Will

Other Ways to Give

Our Wish List

STAY CONNECTED

© 2022 Foothills Country Hospice Society

  • Registered Charity #86144 1053 RR0001
  • Privacy Policy

Your ticket for the: Program Intake Form

Title

Program Intake Form

CAD