INTAKE FORM | MINOR

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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 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)*
Legal Parent or Guardian #1
Name*
Address*
If you are not the legal parent, do you have an order supporting legal guardianship?*
Legal Parent or Guardian #2 (If applicable)
Name
Address
If you are not the legal parent of the minor, do you have an order supporting legal guardianship?
Information: Child/Teen
Name*
Date of Birth (m/d/y)*
Address (If different from above)
Add Child/Teen
Name (First & Last)
Date of Birth (MM/DD/YYYY)
Address if different from above.
 
Emergency Contact:
Name*
Loss Information:
Other Information
I'm interested in:*
Consent*

 

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