INTAKE FORM | MINOR

Name
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 child/teen 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 (Optional)
Phone Number*
Your Email*
Address*
Street Address Address Line 2 City Province Postal Code
Relationship to Child/Teen:*
If you are not the legal parent, 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: Child/Teen
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
Add Child/Teen
Name (First & Last) Date of Birth (MM/DD/YYYY) Address if different from above.
Emergency Contact:
Name*
First Last
Phone*
Loss Information:
Who is the child/teen grieving and what was their relationship to them?*
When did they die?*
How did the person the child/teen is grieving die? (Optional if you would like to tell us)
Did the person die at Pilgrims' Roozen Family Hospice Centre?*
Other Information
Is there anything you’d like to share about the child/teen that would help us create a supportive group experience for them (e.g., attention, emotional, behavioural or learning needs)?*
Do you have any severe allergies we should be aware of? (We often have a snack cart available during our grief sessions.)*
Have you spoken with a member of our grief team? If so, who?
How did you hear about us?*
Consent*
I agree to the privacy policy.
Privacy and Confidentiality
We treat the information you share through this intake form and throughout your grief support with Pilgrims Hospice Society with care and respect. We follow strict confidentiality practices and use your information solely to better understand your needs and provide appropriate support.

Your personal information and the content of your conversations are shared only in ways that support your care and protect your safety.

To meet legal responsibilities: In rare situations, we may be required by law to share information, such as when there is concern about suspected abuse or an immediate risk of harm to yourself or others.

Within our Grief Services team: Relevant information is shared among members of our team to ensure continuity, coordination and the best possible support.

You are welcome to ask questions at any time about how we collect, use and store your information.

By submitting this form, you acknowledge that you understand and agree to these privacy and confidentiality practices.
Security Check

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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Name (First & Last)	Date of Birth (MM/DD/YYYY)	Address if different from above.