Your Name *

Your Email *

Phone Number *

Pet's Name *

Type Of Pet *

Date Of Loss *

Length Of Relationship With Pet *

Circumstances Of Loss? *

What special concerns do you want to address in group?*

Are you experiencing any excessive reactions? *
LonelinessAngerGuiltDepressionLack of AppetiteSleep DisturbancesFatigueSuicidal ThoughtsOther

If OTHER, please specify?

Are you currently receiving any other counseling service? *
YesNo

If YES, for what issues?

Do you feel that you may be in any level of psychological danger? *
YesNo

If YES, for what issues?

Best way to contact you? *
PhoneEmailText

Best time to contact you? *
Morning 7AM-10AMDaytime 10AM-1PMAfternoon 1PM-5PMEvening 5PM-8PM

By checking this box, you agree to the following terms:

In submitting this form, I understand that the information will only be accessed by Pet Loss Hurts Bereavement Counselor. State and federal law requires us to maintain the privacy of your protected health information. I understand that my data will be held securely and will not be distributed to or shared with third parties.

I further acknowledge that this information will NOT be shared in the support group, unless I personally choose to do so. It is strictly used as a guideline for the Bereavement Counselor to assess where I am in my grief journey and to better tailor group sessions to generically address issues of concern.