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Formerly Visiting Nurse

Grief Intake 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.

Are you the individual seeking individual grief counseling?

Personal Information:

Name*
Address*
Date of Birth

Emergency Contact:

Emergency Contact Name

Questionnaire:

Are you currently using drugs or alcohol to cope?

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 4:00 p.m. Monday-Thursday and 1:00 p.m. on Friday. Contact will be made 1 to 3 days after the intake form is submitted.
Are there any barriers to transportation?
Day of Week (choose all that apply):
Time of Day (choose all that apply):

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. 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)*