Congregation Beth El
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Grief Group Inquiry
Name
(Required)
First
Last
Age
(Required)
Gender
(Required)
Email
(Required)
Phone
(Required)
Emergency Contact
Contact Name
Relationship to you
Emergency Phone
Why are you interested in a grief group?
(Required)
Are you currently seeing a counselor (grief or otherwise)?
(Required)
Yes
No
How are you currently coping with your grief? (Check all that apply)
(Required)
Talking to family
Talking to friends
Exercise
Pets
I'm not
Other (please explain)
Other
How would you prefer to meet? (Check all that apply)
(Required)
In a group
Individually
Doesn't matter to me
What else should we know about you?
Any further questions, please contact jewishmentalwellness@gmail.com
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