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Program Intake Form


Thank you for your interest in the Grief and Palliative Support Programs at the Foothills Country Hospice. Please fill in the following form to connect with our programming.

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

Contact Information and Consent

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

Contact Information and Consent

Please fill out your information below.

If the person's residence is not listed here, please select the "Community" option to provide the address.
Please select a referring residence type. *
Which of the following best describes the person you’re referring:
Which of the following best describes the person you’re referring:

Any person referring to a Foothills Country Hospice program is asked to read the following statement to those they are submitting the form on behalf of. This is necessary for FCHS to obtain the rights to follow up for evaluations purposes. Thank you for your support!

Consent Statement: The program you are being referred to is part of the work Foothills Country Hospice Society is undertaking to support our community. We would like to contact you in the future to complete a voluntary follow up survey. The survey will help us understand if we’ve supported a positive change in the community, if we need to make any changes, and to help us secure more funding in the future. *
Consent Statement: The programs you're selecting are a part of the work that Foothills Country Hospice Society is undertaking to support our community. We would like to contact you in the future to complete a voluntary follow up survey. The survey will help us understand if we've supported a positive change in our community, if we need to make any changes, and to 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 the recipient has most recently experienced:
Which of the following best describes your loss?
Age Group of Recipient: *
Age Group: *

Program Descriptions

Please select the program you think is most beneficial for the person you are referring. Descriptions for each program are listed below.

Program Descriptions

Below are descriptions of our program offerings. You're welcome to participate in 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 that those attending 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 that the person you’re referring 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 Program(s) Would You Like to Submit? *

Which of the following programs are you interested in? *

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.
What is the best way for the recipient to receive their Bereavement Box?Please note that our deliveries are typically completed once per week by our volunteer team.
Bereavement boxes may support you following the loss of a loved one by providing role specific, physical grief resources and coping strategies. They are a tangible way for you to have access to resources that you can use in your own time.
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.
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.
Was the death expected?
Compassionate conversations may support you 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.
Was the death of your loved one expected?
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 that those attending be at least 3 months from the date of their loss before attending group. Our Expressive Arts program is offered quarterly.
Which month would the person you're referring like to start participating in the program?
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 that those attending be at least 3 months from the date of their loss before attending group. Our Expressive Arts program is offered quarterly.
Which month would you like to start participating in the Expressive Arts program?
Grief Group is an opportunity for support among others who have similarly experienced a loss. It allows for conversation, compassion, and connection. We recommend that the person you’re referring be at least 3 months from the date of their loss before attending group. Please note - Anyone referred 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.
What is the preferred setting to attend 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 that those attending 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.
What is your preferred setting for attending grief group?
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.
What is the preferred setting to attend 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. Once we've received your intake form, our social work team will call for a brief assessment prior to booking your first appointment.
What is your preferred setting for attending grief counselling?

Thank you for your referral. Please fill out your preferred contact information below. We will only contact you if we have trouble connecting with the person you have referred. 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, we look forward to meeting you,

 

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