Individual & Family Consultation Form

Individual & Family Consultation Form

Participant Information:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact
Phone Number
Format: (000) 000-0000.
The person who died is my:
The type of death/loss
Date of death

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please share why you decided to seek support at this time
What are you hoping to get out of grief support sessions?
Are you currently seeing a therapist? If yes, please provide the name of the therapist, address, and phone number.
Therapist name, address, and phone number.
Do we have permission to contact your therapist if needed? (please check one)
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please carefully read the following, clicking each box below is an indication of agreement and understanding on the lines next to each paragraph and then sign and date on the following page:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
*Please make checks payable to: Companions on a Journey. 8857 Cincinnati Dayton Rd #002, West Chester, OH. 45069 ($90 per session. Payment must be made in full at the time of individual sessions).
Should be Empty: