Virtual Support Group (Bereaved)

Virtual Support Group 
for Bereaved Partners

This support group is a safe landing place for parents whose partner  died of cancer. If your partner died recently, or years ago, and you are  parenting a child through your grief, this is a group for you. Find  connections and support from other parents who can relate to your experience.

Facilitated by Bright Spot Network's Director of Programs and Community Outreach, Carissa Hodgson, LCSW, OSW-C.
Email
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First name
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Last name
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When is your birthday?
/
/
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Phone number
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Street address
(please include apt, unit, suite, floor, etc)
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(please include apt, unit, suite, floor, etc)
City
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State
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Zip code
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We ask the demographic information below to help us tailor programs  and resources to our unique families, build partnerships with other organizations, and secure funding to grow our programs. The information you provide is used in aggregate (not connected to your name or personal information) and never shared outside of the organization.
Gender
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What are your pronouns?
she/her
he/him
they/them
Other
How would you describe your racial background?
(select all that apply)
Asian/Desi/Asian American
Black/African American
Hispanic/Latina/o/Latinx
Indigenous/Native American/Alaskan Native
Middle Eastern/North African
Pacific Islander/Native Hawaiian
White/Caucasian
Prefer not to answer
Other
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(select all that apply)
What type of cancer did your partner have?
Blood (leukemia, lymphoma, multiple myeloma)
Breast
Colorectal (colon, bowel, rectal)
Endocrine (thyroid, parathyroid, pituitary, islet cell, adrenocortical carcinoma)
Eye (retinoblastoma, intraocular melanoma)
Gastrointestinal (esophagus, stomach, liver, gallbladder, pancreas, GIST)
Gynecologic (ovarian, uterine, vaginal, vulvar, fallopian tube, cervical, endometrial, gestational)
Head & Neck (laryngeal, lip & oral cavity, mouth, throat, pharyngeal, sinus, nasal cavity)
Kidney
Musculoskeletal (bone, soft tissue sarcoma, Ewing sarcoma)
Neurological (brain, neuroblastoma, spinal cord)
Penile, prostate, testicular
Respiratory (lung, mesothelioma, thymoma, thymic carcinoma)
Skin (melanoma, Kaposi sarcoma)
Unknown origin
Other
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What were the ages of your children at your partner's diagnosis?
(Check all that apply)
None
Pregnant
Up to 24 months
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
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(Check all that apply)
When did your partner die?
(month / year)
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(month / year)
We ask for the name of an emergency contact and phone number in the  rare instance something urgent happens while you are on a zoom meeting.  We will never use this information unless there is an emergency.
Name of Emergency Contact
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Phone number of Emergency Contact
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Any accessibility needs (i.e. closed captioning, etc.)?
(Write NA if not applicable)
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(Write NA if not applicable)
Is there anything else you'd like us to know?


Please type your initials after every statement if you agree.
I understand that BSN support groups are NOT therapy. If I would like a referral to establish care with a mental health therapist, I will contact BSN who can assist in this process.
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I understand that BSN facilitators are mandated reporters. If information is shared relating to abuse/harm to a child, elder or vulnerable adult, or if someone indicates they are a danger to themself or others, BSN facilitators will report this information to the appropriate agency to provide support and follow-up.
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I understand that there are risks, benefits, and consequences associated with participating in a virtual support group including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
I understand that BSN Support Groups are NOT therapy. If I would like a referral to establish care with a mental health therapist, BSN can assist in this process.
I understand that BSN staff will maintain my confidentiality, with exceptions if it is deemed I am a risk to myself or others, or if information is shared about abuse or harm to children or vulnerable people. I understand that Zoom is not a HIPAA-compliant platform and confidentiality of private information cannot be fully guaranteed.
I understand that BSN Support Groups are NOT intended for crisis situations. If I need immediate assistance, I can call 911 or visit my nearest emergency room. I can also text 741741 to connect with a Crisis Counselor (24/7) or call 1-800-273-8255 to reach the Suicide Hotline (24/7)
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Support Group Expectations

As facilitators we empower group members to take the lead in directing the flow of group. Your lived experience and unique lens provides necessary validation and connection with each other. 

By putting group members in the driver's seat, you can ask each other relevant questions, normalize each other's feelings, and share resources that you've found to be helpful.

We know that making time commitments is hard, however, we also believe that in making the commitment fully, you will receive the most benefit and provide the most support to our community. 

To that end, we ask you to please:

• Join on time with the intention to stay the whole session.
• Come to the group solo: while sleeping babies are welcome, we would like the group session to be a respite from toddlers, older children, and partners—yours and everyone else’s.
• Concentrate fully on the support group. Please do not make us background to another task. For safety, please do not drive during group--if this is necessary, please turn off your camera so you can keep your eyes on the road.
• Understand that this is a support group, not a happy hour. While social events could be a future offshoot of support group, the support group itself is not a place for drinking.
In support of everyone’s emotional needs, please remember that this is a group for cancer and parenting, which everyone handles differently. To that end, we ask that you please:
• Practice reserving judgement: listen openly, respect intentions, and appreciate the opinions and thoughts of everyone, including those you disagree with.
• Keep issues relating to politics and religion specific to how it is affecting your cancer experience. Please refrain from preaching our pushing your beliefs on anyone else in group.
• Share your thoughts and share the space for others to do the same.
Please type your initials below to acknowledge you have read and agree to the above support group expectations.
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How did you hear about Bright Spot Network?
Friend or family member
Health care professional
Bright Spot support group
Other support group
Email
Internet search
Social media - Bright Spot Network (Facebook, Instagram or Twitter)
Social media - from another person or organization
Other
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