HOPE New Beginnings

New Beginnings Intake/Questionnaire
New Beginnings is a support group for people who have completed the 2 year program. Topics discussed are a part of life after 24 months of grieving This is a working group, not a "drop in" social group. Socializing is a secondary benefit of attendance. In order to create a safe group to share, we ask that you commit to attending regularly and to say a proper goodbye when you decide to discontinue.
Name*
Date*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState / Province

Zip
Home Phone
Cell Phone*
Email address*
Do you currently receive the HOPE Connection newsletter?*

YesNo
If not, may we add you?

YesNo
Date Widowed*

MonthDayYear
Date
Years married?*
Spouse Name*
Did you complete the 2 year bereavement group program?*

YesNo
When did you join the program?

MonthDayYear
Date
When did complete the program?

MonthDayYear
Date
Do you feel that you have found some healing in your grief?*

YesNo
What is your reason for joining New Beginnings?*
What are your expectations in joining this group?*
Other information or suggestions that you believe might be helpful?*
Emergency Contact Name*
Emergency Relationship*
Emergency Phone #*
Emergency Address*

Address

Street Address Line 2

CityState / Province

Zip
Mailing Address: PO Box 774, Agoura Hills, CA 91376
Email: info@hopegroups
818-788-HOPE

New Beginnings Agreement
Payment for Services:

The monthly fee for the New Beginnings support group is due at the beginning of each month. Since your membership in group involves the reservation of space specifically for you, missed sessions are not refundable. Your fee will be $40.00 for a 90-minute group session unless other arrangements are made with your facilitator. Payment for the month is $80 if there are 2 groups and $120 if there are 3 groups.

Confidentiality:

All information disclosed within sessions is confidential. Anything that is said by anyone in group or names of persons in your group shall be held in the strictest confidence by all group members. Disclosure by HOPE Connection or the facilitators is allowed and, in some cases, mandated by law in the following circumstances:
- There is sufficient evidence/reason to believe that you may do bodily harm to self or others.
- There is suspected occurrence of child abuse/neglect, elder or dependent adult abuse/neglect, by yourself or someone else, either current or past.
- You are gravely disabled.
The disclosure is required by legal mandate. The disclosure is necessitated by a medical emergency.

General Group Guidelines:
Missed sessions:

If you have an emergency and need to miss a group, contact your facilitator so that we know you will be absent. If 2 groups are missed in a row without notice, you will be dropped from the group roster. Refunds will not be given.

Time Commitment:

You are expected to make at least a four (4) month commitment to the group. This permits you to get a sense of how the group works and encourages you to work through discomforts within the group rather than prematurely leave.

Goodbye to Group:

A minimum of one-month advance notice of intent to terminate is expected. You are expected to attend two consecutive sessions during the termination period. This permits both you and the other group members an opportunity to finish an appropriate goodbye.

This acknowledges that you have read the contents of this document. Your signature on this document acknowledges agreement to these financial terms and gives authorization to HOPE Connection, Inc. to provide support group services after 2 years of grieving.
Member Signature*

Clear
Group Member's Printed Name*
Date*

MonthDayYear
Please verify that you are human*
Mailing Address: PO Box 774, Agoura Hills, CA 91376
Email: info@hopegroups
818-788-HOPE
Should be Empty:

New Beginnings Intake/Questionnaire

New Beginnings Agreement