Name

Email Address

Phone

Date of Contact

Type of Loss / Grief Event Type of Loss / Grief Event What best describes the loss or event that is contributing to your grief? (Check all that apply) Death of spouse/partner Death of parent Death of child Death of sibling Death of grandparent Death of grandchild Death of other family member Death of friend Death of coworker/classmate Anticipatory grief (loved one is seriously ill) Miscarriage, stillbirth, or infertility-related loss Suicide loss Overdose/substance-related death Homicide/violent death Accidental death Death due to chronic illness Death due to sudden medical event Military/service-related loss Loss of pet Separation/divorce/relationship loss Loss of health or physical abilities Loss of employment or financial stability Community tragedy or traumatic event Mass violence/shooting incident Natural disaster Other traumatic event

Other, please list

Did the loss/event occur within our local community? Did the loss/event occur within our local community? Yes No

If related to a community tragedy or traumatic event, please specify:

Date of loss / event

Relationship to the person or event Relationship to the person or event Immediate family member Extended family member Friend Witness/survivor Community member First responder Healthcare worker

Other, please list

Current Needs Checklist Current Needs Checklist I am looking for: Individual sessions with a Grief Counselor Educational Grief Groups Educational Workshops Grief literature/reading materials Invitations to community grief events

MANDATORY AGREEMENT CHECKBOX: I understand that submitting this form does not guarantee services and this is not an emergency hotline or emergency service. MANDATORY AGREEMENT CHECKBOX: I understand that submitting this form does not guarantee services and this is not an emergency hotline or emergency service. Yes