Parents Support Group Registration Form

Parents Supporting Parents: Evolving Through the Loss of a Child

A Jewish Community Initiative supported by Mishkan Miami of the Greater Miami Jewish Federation
Shalom Friend,

Please fill out the following information. This information is completely confidential and will only be seen my the group facilitators. Following receiving this form one of our trained facilitators will reach out to you for a brief conversation. If you have any questions, you may call the director of Mishkan Miami, Rabbi Fred Klein, at 305-562-1235, or rabbiklein@gmjf.org. If you believe there are others who might benefit from this program, please contact us. We will do our best to assist in any way.

This group is intended for a parent(s) who experienced the loss of a teen or adult child. This is a facilitated peer group, in which others may support one another in their grieving journey. It is specifically intended for those who identify with the Jewish community, and when appropriate, Jewish spiritual resources will be shared.
Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your Relationship to the Deceased?
Would you like to add any additional family members that will be participating in the grief support groups? (please do not include primary contact information)

YesNo
Contact Name(s) and Relationship(s) to Deceased:
Bereavement Details

We understand the complex emotions that may come up as you answer the following questions. We collect the following information to provide us with a full picture of your needs and allow us to provide you with the best support.

Feel free to share or not share as much as you feel comfortable. Please take any time needed to complete this section.
Name of the Deceased:
Date of Death:

MonthDayYear
Date
Age at Time of Death:
Please describe the nature of your loss.
Do you have any additional losses?

YesNo
If yes, please explain:
Referral and Additional Details
How did you hear about our services?
Mishkan Miami is planning to establish a private Facebook group for parents both within and outside this group. It is created as a place where people can mark events, ask questions, and share with one another. Would you be interested in joining this group, provided you have a Facebook account?

YesNo
If Yes, please provide your Facebook Name. If there are others you would like us to invite, please add their names below. Please note they do not need to be in the support group to participate in the Facebook Group.
Are there additional families and or individuals you would like us to invite to join this support group? If so please enter their names and contacts below. (Name, Number & Email)
Standards of Participation

1. Confidentiality

By participating in this group, members commit to ensure the confidentiality of the participants. This builds trust among the members.

2. Attendance and Continuity

Regular attendance at groups is very important to build a healing community. If possible, allow your family to attend groups for at least 4 consecutive weeks following orientation to best gauge whether the Mishkan Miami group is a good fit for you and your family. If you have concerns, we ask you to speak to the facilitators.

3. Referral and Emergency Services

Mishkan offers peer support groups for bereaved families. They do not provide private therapy or counseling services to individuals and families. When requested by a family, we provide the names of several therapists or resources as referrals. The family is responsible for selecting the resource of their choice.

4. Visitors

No visitors, please. Because of confidentiality issues, we ask you not to bring additional family members, friends, or other guests to groups. All participants must attend an orientation session to assure a consistent awareness of group rules.
Please confirm the acceptance to these standards

YesNo
Should be Empty:

Parents Supporting Parents: Evolving Through the Loss of a Child

Shalom Friend,

Bereavement Details

Referral and Additional Details

Standards of Participation

1. Confidentiality

2. Attendance and Continuity

3. Referral and Emergency Services

4. Visitors