Grief Group Enrollment | Central Illinois Resource Center Inc

First Name*

Last name*

Your email*

Zip Code*

Parent or Legal Guardian's First & Last Name:*

Parent/Legal Guardian Phone Number:*

Do you reside within the State of Illinois?*

Yes

This group is a peer-support grief group hosted by Central Illinois Resource Center Inc. (CIRC) in partnership with Hope From Horses. The purpose of this group is to provide a supportive space where individuals experiencing grief or loss can share, listen, and connect with others. I understand and acknowledge that: Participation does not create a therapist-client, medical, or legal professional relationship with Central Illinois Resource Center Inc., Hope From Horses, or any facilitators. I acknowledge that participation in the group is voluntary, and I may choose how much or how little I share.*

I agree

I disagree

To help maintain a safe and respectful space for participants, I acknowledge and agree to the following: • I will respect the privacy of other participants and will not share personal stories, names, or identifying information discussed in the group outside of the session. • I understand that while facilitators encourage confidentiality, Central Illinois Resource Center Inc. cannot guarantee that all participants will maintain confidentiality. • I understand that sessions may take place through Zoom or another virtual platform, and while reasonable precautions are taken, complete privacy or security of online communications cannot be guaranteed. • By choosing to participate, I voluntarily agree to participate in this peer-support group and release and hold harmless Central Illinois Resource Center Inc., Hope From Horses, their staff, volunteers, facilitators, and partners from liability arising from participation in the program, to the fullest extent permitted by law.*

I agree

I disagree

Central Illinois Resource Center Inc. (CIRC) is committed to maintaining a safe, respectful, and supportive environment for all participants. Any individual whose behavior is determined by group facilitators or CIRC staff to pose a risk, disruption, or safety concern to the group or its participants may be removed from the session immediately, with or without prior warning or stated cause, at the sole discretion of Central Illinois Resource Center Inc. By participating in this group, I understand and agree that Central Illinois Resource Center Inc. reserves the right to deny participation or remove any individual in order to protect the safety and wellbeing of the group. I further acknowledge that Central Illinois Resource Center Inc. reserves the right to report incidents to appropriate authorities and pursue legal action, including pressing charges to the fullest extent permitted by law, for any alleged unlawful conduct, threats, harassment, or criminal activity occurring in connection with this program.*

I acknowledge and agree to the group safety and conduct disclosure.

I confirm that I am 12 years of age or older. *

Yes

Holding Hope

Your grief. Your pace.

A grief support group for teens ages 16–19

Grief looks different for everyone. Whether your loss is recent or something you’ve been carrying for a while, this group offers a supportive space where you don’t have to explain yourself—or have it all figured out.

This is a place to talk, listen, or simply be present. No pressure. No judgment. Just support from others who understand that grief doesn’t follow a timeline.

Central Illinois Resource Center Inc

Empowering lives through advocacy and support.

Support Info:

info@centralillinoisresourcecenter.org

+1 (309) 981 7233

Central Illinois Resource Center Inc is an Illinois Not-for-Profit Corporation with an Active 501(c)3 Status under the Internal Revenue Code. Central Illinois Resource Center Inc operates for Community Benefit.

Central Illinois Resource Center Inc covers Peoria, Tazewell, Woodford, Fulton, Knox, Livingston, Mason, McLean, Sangamon and Stark Counties.

PO BOX 5065
PEORIA, ILLINOIS, 61601