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Stillwater Hospice
(260) 435-3222

Individual Counseling Enrollment Form

The Peggy F. Murphy Community Center serves adults 18 and older and children ages 10-17 on a case by case basis. Please fill out the form below to apply for services.

"*" indicates required fields

Are you the individual seeking individual grief counseling?*

Personal Information:

Name*
Address*
Date of Birth*

Questionnaire:

What, if any, mental or emotional health concerns or diagnoses do you have? Please check all that apply.

Information About the Deceased:

Name of deceased*
Date of death*
Was this a Stillwater Hospice Patient?*

Preferences:

The latest appointment accepted at the Community Grief Center is at 4:00 PM Monday through Thursday and 1:00 PM on Friday. Contact will be made 1 to 3 days after the enrollment form is submitted.
Are there any barriers to transportation?*
Day of week (choose all that apply):*
Time of day (choose all that apply):*
What, if any, grief programs would you be interested in? Check all that apply.*
What has prevented you from choosing grief programs in the past? Check all that apply.*

Emergency Contact:

Emergency Contact Name

Demographic Info:

Please help us provide grief support to those in need by providing the following data. This information is used to help secure and report on funding to help support our individual grief counseling services, support groups, and programs. No individual’s data will be shared. Thank you.
Hispanic?*
Do You Identify as Any One of the Following Groups (Please choose all that apply)*
How did you hear about The Peggy F. Murphy Community Grief Center?*