Pre-Register Bereavement Support Group

Pre-Register

Bereavement Support Group

If you are a caregiver who lost a spouse/partner after transplant or CAR-T cell therapy within the last 3-48 months, we invite you to join this online bereavement group. The group will meet monthly via Zoom, and members can attend as often as needed.

The group is led by a licensed psychologist with expertise in transplant, CAR T-cell therapy, and caregiving, as well as grief, death, and loss. The focus of each group meeting will be tailored to the needs of the participants and may include topics such as stages of grief, coping with loss and challenging emotions, adjusting to life now, and self-care after caregiving.

Bereavement Support Group

First Name

Last Name

Phone Number

Phone Type

Cell

Landline

Street Address

Street Address Line 2

City

State/Province

Postal Code

Country

Your Birth Month and Year

Your Birth Month and Year: Month

Your Birth Month and Year: Year

Patient Info & Relationship

Relationship to Patient

Patient First Name

Patient Last Name

Patient's Birth Year

Patient's Birth Year: Year

Diagnosis Info

Diagnosis

Type in diagnosis to see list or select Other and complete the disease description.

Disease Description -

If your disease was not listed above enter it here.

What type of therapy did the patient have?

Transplant - bone marrow, stem cell or cord blood

CAR T-Cell Therapy

Unsure

Other…

Transplant Info

Number of Transplants

Date of Most Recent or Possible Transplant

Date of Most Recent or Possible Transplant: Month

Date of Most Recent or Possible Transplant: Year

Patient Age at time of transplant

Your Age at time of their transplant

Transplant Center Name

CAR T-cell Therapy

Date of CAR T-Cell Therapy

Date of CAR T-Cell Therapy: Month

Date of CAR T-Cell Therapy: Year

Patient Age at time of CAR T-Cell Therapy

Your age at time of their CAR T-Cell Therapy

Center Name for CAR T-Cell Therapy

General Contact Info

Do you speak languages other than English?

Yes

I agree to keep the names and comments of all participating in the group discussions confidential.

This support group is for the caregiver who has lost a Spouse/Partner. Since you did not check that you are the Spouse/Partner, please check out our other support groups.

Pre-Register

Bereavement Support Group

This support group is for the caregiver who has lost a Spouse/Partner. Since you did not check that you are the Spouse/Partner, please check out our other support groups.

If you have any questions, please email Michala at michala@bmtinfonet.org.