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Your privacy - how will we use your data 

 Calvary Health Care Bethlehem is committed to protecting your privacy. 

 Your personal information will only be used to care for you as part of our online Bereavement Support Group.

I agree to the above terms and conditions. *

About you

First name

Last name

Phone number *

Email address

Address *

Street address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Date of birth *

Country of birth *

AustraliaOther

Please specify: *

Language(s) spoken *

Are you of Aboriginal or Torres Strait Islander origin? *

Yes - AboriginalYes - Torres Strait IslanderNoPrefer not to say

Do you identify as being part of the LGBTQI+ community?

YesNoPrefer not to say

Do you have a disability? *

YesNoPrefer not say

Please provide further details: *

Do you have any access or inclusion needs? (e.g. communication aids, hearing difficulties, cultural or language considerations) *

YesNo

Please provide further details: *

Your emergency contact

Name

Contact number *

Relationship to you: *

About the person you cared for

Name *

Date of birth *

Your relationship with the person you cared for:

SpouseParentChildGrandparentGrandchildFamily memberFriendOther

Please specify: *

Date of death: *

Is the person you cared for of Aboriginal or Torres Strait Islander origin? *

Yes - AboriginalYes - Torres Strait IslanderNoPrefer not to say

Did the person you cared for live with you? *

YesNo

Please provide their address: *

Street address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

About this group

What do you hope to get out of attending the support group? *

Do you have any concerns in relation to the support group? *

YesNo

Please tell us more about your concerns: *

Over the past fortnight, how would you rate your level of distress on scale of 1-10? *

1 - not at all stressed2345678910 - the most distressed I've ever felt

Over the last fortnight, how often have you been able to talk with other people who understand how you feel?

NeverHardly everSometimesOften

How did you hear about this group? *

Calvary websiteBereavement card flyerFriend or colleagueLocal palliative care serviceNot sureOther

Please specify: *

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Your consent

Calvary Health Care Bethlehem is committed to protecting your privacy. Your personal information will only be used to care for you as part of our online Bereavement Support Group.

I have read and understand the information about the online bereavement support group. *

I consent to participating in the 7 sessions and following the guidelines for participation outlined at the start of this form. *

I consent to the use of my personal information for the purposes of care provision and data reporting in line with the Victorian Department of Health guidelines. *

 

To learn more about how we safeguard your information, please review our Privacy Policy here.

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