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?

I am filling this out for myselfI am a professional referring someone else

Contact Information

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

First Name *

Last Name *

Phone Number *

Email Address *

Gender Identity *

How would you prefer to describe your gender?

Personal Information

Please fill out your information below.

First Name *

Last Name *

Phone Number *

Email Address *

Gender Identity *

How would you prefer to describe your gender?

Current Address

Please select which of the following best describes the individual's current residence: *Supportive Living or Long-Term CareHospitalCommunity Address

Supportive Living or Long-Term Care Locations

Hospital Locations

Please provide the address:

Do you currently live in a retirement community, supportive living, or long-term care location?YesNo

Supportive Living or Long-Term Care Locations

Please provide your address:

Consent

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

Yes, they are aware

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. *Yes, I agree to being contacted for evaluation in the futureNo, I do not agree to being contacted

Please indicate the preferred mode of contact for follow up:EmailPhone

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.

Bereavement Boxes

What is the best way for this individual to receive their Bereavement Box?Delivered to provided addressPick up from the hospicePlease note: deliveries are typically completed once per week by our volunteers.

Bereavement Boxes

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.I will pick up my box from the front desk of the hospiceI live in supportive living and am requesting a deliveryPlease note that our deliveries are typically completed once per week by our volunteer team.

Compassionate Conversations

Was the death expected?YesNo (unexpected/sudden)

Briefly describe the circumstances of the loss or additional important information that would impact the phone call:

Compassionate Conversations

Was the death of your loved one expected?YesNo (unexpected/sudden)

Expressive Arts

Which month would the person you're referring like to start participating in the program?June 2023September 2023December 2023

Expressive Arts

Which month would you like to start participating in the Expressive Arts program?June 2023September 2023December 2023

Grief Group

What is the preferred setting to attend grief group?On-site at Foothills Country HospiceVirtually (zoom)

Grief Group

What is your preferred setting for attending grief group?On-site at Foothills Country HospiceVirtually (zoom)

Grief Counselling

What is the preferred setting to attend grief counselling?On-site at Foothills Country HospiceVirtually (zoom)

Grief Counselling

What is your preferred setting for attending grief counselling?On-site at Foothills Country HospiceVirtually (zoom)

Is there any additional information you’d like us to know?

Is there any additional information you’d like us to know, so we can best support you?

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

First Name *

Last Name *

Email Address *

Phone Number

Program Intake Form

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

Please fill out your information below.

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

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Program Intake Form