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Grief Support Consent Form – MinorPaige Tirs2025-11-13T17:19:49-07:00

INTAKE FORM | MINOR

URL
This field is for validation purposes and should be left unchanged.
* Required Fields
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 to focus on while accessing grief support services through Pilgrims Hospice Society. A grief support team member will contact you (the legal parent or guardian) via phone call within 1-3 business days. If you feel as though yourself, or the minor in your care, is a risk to themselves or others, please call 911 or go to your nearest emergency room department.
Today's Date (m/d/y)*
Month
Day
Year
Legal Parent or Guardian #1
Name*
First Last
Pronouns*
Phone Number*
Your Email*
Address*
Street Address Address Line 2 City Province Postal Code
Relationship to Minor:*
If you are not the legal parent of the minor, do you have an order supporting legal guardianship?*
- Yes
- No
- Unsure
Legal Parent or Guardian #2 (If applicable)
Name
First Last
Phone Number
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Minor
If you are not the legal parent of the minor, do you have an order supporting legal guardianship?
- Yes
- No
- Unsure
Information: Minor
Name*
First Last
Date of Birth (m/d/y)*
Month
Day
Year
Address (If different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact:
Name*
First Last
Phone*
Formal Support Information:
Does the minor currently see a therapist or other mental health professional?*
Yes
No
If Yes to the above question:
For how long has the minor seen a mental health professional?
Has the mental health professional helped the minor with their grief?
Does the mental health professional know that the minor is accessing grief support services through Pilgrims Hospice Society?
Does the minor currently have a mental health diagnosis that will impact their ability to participate in a grief support group?
Yes
No
Unsure
Loss Information:
Who is the minor grieving?*
What is the minor’s relationship to the person they are grieving?*
What is the date (or anticipated timeframe) of this person’s death?*
How did the person the minor is 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 the minor is coping with the loss? What are some things they are doing to get through this time?*
Does the minor currently have people in their life who can provide support to them as they grieve? If no, please explain.*
Has the minor exhibited a change in behaviour, personality, or performance (in school, sports, interests, etc.) since the death? 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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Administration:
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8:30am- 4:30pm

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Pilgrims Hospice Society acknowledges that we are located on Treaty 6 territory and respects the histories, languages and cultures of First Nations, Métis, Inuit and all First Peoples of Canada, whose presence continues to enrich our vibrant community.
Charity # 89704 1455 RR0001
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