Bereavement Support Request Name * Required First Last Phone * RequiredEmail * Required What type of loss have you experienced? * Required Spouse / Partner Child Adult Child Parent Sibling Other Family Member Friend Other Date of Loss: * RequiredI am interested in the following supports: * Required Bereavement Support (one on one) Bereavement Support Group Bereavement Walking Group Which community do you live in? * RequiredBurlingtonHalton HillsMiltonOakvillePermission to Submit * Required I agree Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8800 if you do not wish to submit this information online and we will be happy to assist you.