Registration for in-person and online Bereavement Support Groups - Journey Through LossJourney Through Loss

Please note that because registered participants can attend either the On-line or In-person group, some of the following points are more pertinent to the On-line group.

By participating in the Journey Through Loss Bereavement Support Group, you are agreeing that the confidentiality and privacy of all participants will be upheld. This is accomplished by ensuring the following:

• There is no one else present with you during the session who has not completed an intake process.
• You are in a private location.
• You are not taking screen shots or recording the session visually or audibly.
• You agree not to share the link to the Virtual Group with other members, friends, etc.
• You agree not to disclose any personal detail of any group member to anyone outside of the group itself.
• You agree that if you leave the session without notice, we may follow up with you by phone or email.

Liability Waiver for Journey Through Loss

This waiver of liability includes any risk of attending in-person sessions, engaging in online sessions, or attending any events, or other bereavement support group services (“Services”) provided by Journey Through Loss (“JTL”). By agreeing to this waiver:
• You understand that JTL Services are not offered as a substitute for medical care and are not intended to diagnose or cure any mental health or medical conditions. Also, you understand that our facilitators are not acting as medical or mental health professionals.
• You understand and agree that you are fully responsible for your own well-being during your access to the Services, and you are responsible for making your own choices and decisions.
• You understand that the information you provide to us will be shared with other JTL facilitators. This information cannot be released without your informed and written consent, except:
i. in circumstances where we have a duty to report child abuse and neglect,
ii. when there is a threat of harm to yourself or others, or
iii. when we are served with a court order.
• You understand that all comments and feedback offered by our facilitators are for the sole purpose of assisting you in achieving your goals. You will be able to give informed consent, and hereby give such consent to the facilitator(s) to assist you in achieving such goals.
• You understand that the use of technology is not always secure and accept the risks to confidentiality in the use of email, text, phone, online services and any other technology.
• You hereby release, waive, acquit and forever discharge JTL, including, but not limited to: JTL or its directors, volunteers, students, and their respective successors and representatives, from every claim, suit action, demand or right to compensation for damages claimed or that you may have arising out of your own acts or omissions or acts and omissions of JTL or its directors, volunteers, students, and their respective successors and representatives, as a result of any advice given otherwise resulting from the relationship contemplated by this agreement.
By clicking “Submit” I acknowledge I have read and understand the provisions in this form and consent to same.

Fill in the information below and click submit. You will receive an email within 24 hours with details to join the group.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

Province

Code Postal

Phone *

Email *

Date / Time *

Date

Time

By clicking this Acknowledgement, you agree to adhere to the above guidelines and liability waiver to participate. *

I Agree to the Following Guidelines and Liability Waiver

If you have NOT previously had a live intake telephone interview with a JTL facilitator, you will be contacted directly to complete the intake interview prior to your first scheduled online or in-person meeting.

Intake Interview *

I HAVE previously had a live intake telephone interview with a JTL facilitator
I HAVE NOT previously had a live intake telephone interview with a JTL facilitator

As a registered member, you are able to attend either the online or in-person group. Please tell us how you would like to attend group initially.

Group Preference *

I would like to register for the in-person Bereavement Support Group
I would like to register for the online Virtual Bereavement Support Group

Please tell us how you heard about us (e.g., online, another member, funding partner, healthcare professional, etc) *

Online Group Please Note: While every attempt is made to assist individuals with registering to attend the online virtual bereavement group, it is expected that participants will be willing to download the necessary (free) software to their electronic device. This is a necessary requirement to gain accessibility to the online group.

Name