Virtual Family Support Group Interest Form

Legacy Lifecare (Chelsea Jewish Lifecare & JGS Lifecare) recognizes the pain and agony our families are feeling during this COVID-19 pandemic and is offering a virtual family support group to our residents’ loved ones.

In this two session group series, participants will have an opportunity to share their thoughts and feelings in a supportive and safe space while connecting with other families who truly empathize. During each session, helpful coping strategies and other resources will be shared by our experienced social workers.

To inquire about the group or express interest in joining, please fill out this form and a facilitator will contact you directly.

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* 1. Contact information

Name

Email Address

Phone Number

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* 2. Resident name

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* 3. Relation to resident

My Spouse/Partner

My Parent

My Mother-in-Law/Father-in-Law

My Grandparent

My Aunt or Uncle

My Sister or Brother

My Child

My Friend

Other (please specify)

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* 4. Resident location

Brudnick Center for Living

Katzman Center for Living

Leavitt Family Jewish Home

Leonard Florence Center for Living

Estates on Admiral's Hill (Cohen Florence/Florence & Chafetz)

Kaplan Estates

Ruth's House

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* 5. How did you hear about the Virtual Family Support Group? Please check all that apply.

Family letter

Other families or friends

Staff

Website

Social Media

Other (please specify)

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* 6. What is your primary interest in joining a family support group? Please check all that apply.

Reduce feelings of loneliness and isolation

Reduce anxiety and stress about your loved one

Opportunity to openly share your emotions with others

Gather information and learn coping skills

Meet and be with others who share similar experiences

Other (please specify)

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* 7. Please select which days and times work best for you to attend sessions.

	Morning (9am-12pm)	Afternoon (1pm-4pm)	Evening (6pm-8pm)
Monday	Monday Morning (9am-12pm)	Monday Afternoon (1pm-4pm)	Monday Evening (6pm-8pm)
Tuesday	Tuesday Morning (9am-12pm)	Tuesday Afternoon (1pm-4pm)	Tuesday Evening (6pm-8pm)
Wednesday	Wednesday Morning (9am-12pm)	Wednesday Afternoon (1pm-4pm)	Wednesday Evening (6pm-8pm)
Thursday	Thursday Morning (9am-12pm)	Thursday Afternoon (1pm-4pm)	Thursday Evening (6pm-8pm)
Friday	Friday Morning (9am-12pm)	Friday Afternoon (1pm-4pm)	Friday Evening (6pm-8pm)

Virtual Family Support Group Interest Form

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* 1. Contact information

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* 2. Resident name

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* 3. Relation to resident

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* 4. Resident location

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* 5. How did you hear about the Virtual Family Support Group? Please check all that apply.

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* 6. What is your primary interest in joining a family support group? Please check all that apply.

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* 7. Please select which days and times work best for you to attend sessions.

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* 8. What questions do you have about the Virtual Family Support Group?