First Name *

Last Name *

Email *

Phone

Mother's Name (first and last) *

Date of Mother's Death

This is not required but it's useful for us (Susanna + Randi) to know both how long it's been and when the day is, in case it falls during our group. Please only share if comfortable.

Your Children's Names and Ages

How would you like to use our time in group? Check all that apply: *

Have a regular time and space to feel and process my grief

Plan for handling holidays, birthdays, Mother’s Day, anniversary of death, etc.

Consider how to make sure my kids know my mom

Consider my mom’s legacy and how to integrate it into my life

Consider my own legacy and how to move forward with my life as I grieve

Other (please describe below)

Other

Describe the support you have received since your mother’s death:

Were you/are you satisfied with the support you have received? Why or why not?

Describe any other significant losses you have experienced in your life:

Where are you with your grief? How does your grief show up for you? Tell me a little about your grief journey.

Share one thing you loved about your mother or a fond memory of your mother:

Are you able to do basic daily activities such as dressing, eating, sleeping, etc most of the time? *

Grief coaching is not a substitute for counseling, therapy or any kind of mental health services. We strongly encourage clients who may need this kind of support to get it! We are happy to work with clients who are also receiving mental health services. Although we are social worker, we are not licensed to provide therapy or counseling. If you are experiencing suicidal thoughts, please call The National Suicide Prevention Lifeline (1-800-273-8255) or contact the Crisis Text Line by texting HOME to 741741. Have you experienced suicidal thoughts since your mother’s death? *

How did you find out about this group?