8 Wk Bereavement 2012

The program will be held at Karpas Health Information Center: 311 1st Avenue at 18th Street.

8 Tuesdays: September 18, 25; October 2, 9, 16, 23, 30; November 6. 6:30-8:15pm

* Sex

Male

Female

* Age

* First Name

* Last Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Email Address

* Loss of

* Date of Loss

* Have you ever attended a bereavement program before?

Yes

No

* If so what type?

* Is there anything in particular you are looking for from the group experience?

* In addition to the current loss, what other losses have you experienced. ( i.e. family/friend/pet)?

* Cost of Workshop

$320

* How do you want to pay?

Credit Card (+ 2.9% Processing fee)

Check

* Indicates Response Required