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?

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

Resident Contact Infromation

Contact Information and Consent

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

First Name *

Last Name *

Phone Number *

Email Address *

Gender Identity *

How would you prefer to describe your gender?

Contact Information and Consent

Please fill out your information below.

First Name *

Last Name *

Phone Number *

Email Address *

Gender Identity *

How would you prefer to describe your gender?

Residence:If the person's residence is not listed here, please select the "Community" option to provide the address.

Please select a referring residence type. *Supportive Living or Long-Term CareHospitalCommunityFuneral Home

Home Address:

Supportive Living or Long-Term CareCommunity

Address:

Residence Location

Supportive Living or Long-Term Care Locations

Address:

Hospital Locations

Address:

Community

Address:

Funeral Home Locations

Address:

Which of the following best describes the person you’re referring:A residentFamily of a resident

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

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. *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

When was the loss experienced?0-3 months4-6 months6-12 months> 1 year

When did you experience your loss?0-3 months4-6 months6-12 months> 1 year

Which of the following best describes the type of loss the recipient has most recently experienced:Loss of a SpouseLoss of a ParentLoss of an Adult SiblingGeneral Loss (Child Recipient)General Loss (Adult Recipient)

Which of the following best describes your loss?Loss of a SpouseLoss of a ParentLoss of an Adult SiblingGeneral Loss (Child Recipient)General Loss (Adult Recipient)

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.

Bereavement BoxesBereavement 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?Delivered to provided addressPick up from the hospicePlease note that our deliveries are typically completed once per week by our volunteer team.

Bereavement BoxesBereavement 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.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 ConversationsCompassionate 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?YesNo (Unexpected/Sudden)

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

Compassionate ConversationsCompassionate 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?YesNo (Unexpected/Sudden)

Expressive ArtsExpressive 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?March 2023June 2023September 2023December 2023

Expressive ArtsExpressive 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?March 2023June 2023September 2023December 2023

Grief GroupGrief 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?At Foothills Country HospiceVirtually (Zoom)

Grief GroupGrief 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?At Foothills Country HospiceVirtually (Zoom)

Grief CounsellingGrief 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?At Foothills Country HospiceVirtually (Zoom)

Grief CounsellingGrief 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?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?

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.

First Name *

Last Name *

Email Address *

Phone Number

Technical Support

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,

Program Intake Form

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.

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Program Intake Form