Please complete the from to the best of your ability and discretion. Any information that you submit here is strictly used to create a better support group experience for you. No personal details will be disclosed during the sessions, unless you choose to share.

Are you experiencing any excessive reactions? *

Are you currently receiving any other counseling service? *

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

Best way to contact you? *

Best time to contact you? *

In submitting this form, I understand that the information will only be accessed by Pet Loss Hurts Certified Pet Loss and 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 Certified Pet Loss and Bereavement Counselor to assess where I am in my grief journey and to better tailor group sessions to generically address issues of concern.