APPLICATION FORMS

Thank you for your recent call to the Healing Patch…A Program for Loss & Hope. The Healing Patch offers a safe place where children and families come to know that they are not alone in their grief. We provide family members opportunities to work on their grief experience with others that have encountered a similar loss. Sharing feelings and experiences in an atmosphere of acceptance, families discover that what they are going through is normal and that hope and healing are possible. Available at no cost to families, The Healing Patch is open to children of all ages (preschool up to age 18) who can benefit from a peer support group. 

Please refer to your initial email for the date/time of your family orientation at UPMC Home Healthcare (20 Sheraton Dr. Altoona, PA 16601). The orientation will provide an opportunity for your family to learn more about our services and possibly meet other grieving families. Please make every effort to attend. All families are required to participate in a Family Orientation prior to enrollment. If for some reason you should have a conflict with scheduling, other arrangements will be made. If you are unable to attend, please contact the Healing Patch staff for your group listed below. You are also welcome to bring material/clothing to have a memory bear made for the child(ren).

Tuesday group - Healing Patch Coordinator Melody Ray - This email address is being protected from spambots. You need JavaScript enabled to view it. or 814-947-7200
Wednesday group - Healing Patch Volunteer Coordinator/Grief Specialist - This email address is being protected from spambots. You need JavaScript enabled to view it. or 814-947-7140 

Please take a moment to complete all of the forms below. If you choose to print, please bring these completed forms along with you to the scheduled Family Orientation. 

Family Application | Print Version

Individual Child Application (must be completed for each child) | Print Version

Consent for Photos* | Print Version
*Each adult attending the group must complete a separate Consent for Photos authorization. Child(ren) need to be reflected in only one form.