Privacy Practices & Medical Records

Please select the support group(s) you are interested in from the checklist below. Fields marked with an asterisk (*) are required. Please fill in the form and click “Submit” to send us the form. Once we receive the form, a member of the Grief Services staff will contact you to confirm the dates of the next group(s) and to complete your registration. If you have any questions, please call Pathways for Grief & Loss at 970.663.3500 or bereavement@pathways-care.org.

Support Group and Events*

First Name*

Last Name*

Address*

City*

State*

Zip*

Primary Phone Number*

Please indicate if this is a mobile, home or work number

Mobile

Home

Work

Secondary Phone Number

Please indicate if this is a mobile, home or work number

Mobile

Home

Work

Email Address*

Date Of Birth

Where did you hear about Pathways for Grief & Loss?

First Name of the Deceased

Last Name of the Deceased

Relationship to the Deceased

Date of Death

Age at Death

Place of Death

Cause of Death

Were they a hospice patient with Pathways?

Yes

No

Not Sure

Have you experienced any other losses in the past year?

Consent & Submit*

I consent to allow Pathways to collect the information on this form.

*Information included on this form is protected by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 and will remain confidential between the applicant and group facilitators and will not be shared with the group without specific permission.