INTAKE FORM | ADULT

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Please fill out the below information to the best of your ability. Although we recognize that many people may experience multiple death-related losses, please choose one loss that you would like to focus on while accessing grief support services through Pilgrims Hospice Society. A grief support team member will contact you via phone call within 1-3 business days. If you feel as though you are a risk to yourself or others, please call 911 or go to your nearest emergency room department.
Today's Date (m/d/y)*
Month
Day
Year
Name*
First Last
Date of Birth (m/d/y)*
Month
Day
Year
Pronouns*
Primary Phone Number*
Your Email*
Address*
Street Address Address Line 2 City Province Postal Code
Emergency Contact:
Name*
First Last
Phone*
Formal Support Information:
Do you currently see a therapist or other mental health professional?*
- Yes
- No
If Yes to the above question:
a) For how long have you seen a mental health professional?
Has your mental health professional helped you with your grief?
Does your mental health professional know that you are accessing grief support services through Pilgrims Hospice Society?
Do you currently have a mental health diagnosis that will impact your ability to participate in a grief support group?*
- Yes
- No
- Unsure
Loss Information:
Who are you grieving?*
What is your relationship to the person you are grieving?*
What is the date (or anticipated timeframe) of this person’s death?*
How did the person you are grieving die?*
Did your loved one die at The Roozen Family Hospice Centre?*
Coping Information: Coping can be understood as things we do to help ourselves live with our grief.
How do you feel you are coping with your loss? What are some things you are doing to get through this time?*
Do you currently have people in your life who can provide support to you as you grieve? If no, please explain.*
Have you spoken with a member of the grief team? If so, who?
How did you hear about us?*
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Monday – Friday
8:30am – 4:30pm

Pilgrims Hospice Society: 9808 – 148 Street in Edmonton
For more information contact us at 587-414-1148 or by email at griefsupport@pilgrimshospice.com

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