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 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.