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• Surviving Loss - A Support Group for Grief

• Join the space we have created to explore the pain of loss.

• Tuesday at 6:00pm

• Starting Date TBD

• Sessions will be conducted via Zoom

Facilitator(s): Katie Martin, MSW, LICSW Candidate, Dani Baker, MSW, LICSW Candidate and Dara McWeeney, BS, CMHC Intern

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Most insurances will cover the cost of group sessions.
Speak to our Group Coordinator for questions regarding insurance or self-pay rates.

How to Join:
To inquire further about groups, please contact our Groups Coordinator at 603-865-1321 option 3, or you can

Register for this Group

Who is completing this request? *

Please select an option Parent / Guardian Myself Service Provider

Your name
Agency name
Agency Phone Number	(do not include 1- prefix)
Agency E-Mail Adr
Is the individual aware you are referring them to this group?	Yes    No Please choose yes or no
May we contact you regarding this referral if needed?	Yes    No Please choose yes or no

Why are you interested in this group?
Participant First Name *
Participant Last Name *
Date of Birth * (mm-dd-yyyy)
Address*
Parents Name (if Client under 18)
Communication Preference	Phone    Email Please choose yes or no
Phone *	(do not include 1- prefix)
OK to Leave Message *	Yes    No Please choose yes or no
E-Mail Adr

Do you have Health Insurance ? *

Please select an option Yes I do No Insurance

Insurance Carrier *
Insurance ID# *

Secondary Insurance
ID Number
How did you hear about this Group? *
If you were referred to this Group, who referred you? *
(* required info)