Bereavement Program Application

New England Hospice Bereavement Program Application

New England Hospice offers a close-ended Virtual Group Bereavement Program.
This is an 8-week group program that will run once a week with the same participants. During these virtual group sessions, there will always be facilitators, including New England Hospice Social Workers, guiding the group to help sessions run smoothly.

If you are interested in this program, please fill out the application below and we will be in contact with you shortly.

If you have any further questions, please email JPeterson@newenglandhospice.com or call (781) 749-2900

Contact Information

* Indicates required field

Name *

First

Last

Address *

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City

State

Zip Code

Country

Preferred Name *

Gender *

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Date of Birth *

Email *

Mobile # *

Home # *

Permission to Contact *

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Permission to text session reminders *

Yes No

Emergency Contact Information

Name *

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Last

Phone # *

Relationship to Emergency Contact *

Personal Information

Name of Person Who Died *

Date of Death *

Relationship with the Person Who Died *

Please indicate if death was by COVID-19

Other Information

Briefly share any primary concerns or goals you have from this service: *

Additional Comments: *

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