End-of-Life and Grief Support Application

Today's Date*

Date

Applicant's Name (Parent or Guardian)*

First NameLast Name

E-mail*

example@example.com

Phone (mobile preferred)*

Applicant's gender preference

Relationship to child

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Second Parent or Guardian

First NameLast Name

Second person's email

example@example.com

Second person's Phone (mobile preferred)

Second person's gender preference

Second person's Relationship to child

Second person's Relationship to applicant

Will second person participate in support sessions when able?

Please identify your family's ethnicity for our DEI tracking (select all that apply)

Does your child have a terminal diagnosis or are they deceased?*

We are at the end-of-life stage of our child's diagnosisOur child has passed away and we are in need of grief support

Which of our support people would you like to work with? Please choose one. See our website for descriptions of what they each offer*

Bittersweet - Beecher Grogan (Lebanon, ME)Sacred Oak - Lori Mangano (Exeter, NH)I would like to schedule a 30-min zoom session with both providers to determine who will be the best fit for our family.

Who are you looking for support for:

Myself onlyMe and my child's other parentMy child(ren) onlyOur full family

Have you worked with or are you still working with any other integrative therapists? Please describe who received therapy and what types.

This includes homeopathy, acupuncture, reiki, art, music, meditation, or talk therapy.

Should we know of any particular spiritual considerations your family may have?

Name of child transitioning or deceased (if you have more than one deceased child, please indicate below the Siblings' info below)*

First NameLast Name

Child's Birthday

Date

Child's gender preference

Child's Diagnosis(es)

If your child died suddenly, please skip this question or type NA

Date of Primary Diagnosis

Date

If your child has passed away, what is their date of death

Date

What was their age at passing?

Feel free to share a little about their diagnosis and medical history below (optional)

All sensitive information in this form is HIPAA-compliant and password-protected.

Surviving Sibling 1

First NameLast Name

Sibling 1 Birthday

Date

Sibling 1 gender preference

Surviving Sibling 2

First NameLast Name

Sibling 2 Birthday

Date

Sibling 2 gender preference

Surviving Sibling 3

First NameLast Name

Sibling 3 Birthday

Date

Sibling 3 gender preference

Surviving Sibling 4

First NameLast Name

Sibling 4 Birthday

Date

Sibling 4 gender preference

If you have another deceased child or more children in your family, please list them with their birthday and gender preference below

Please list an emergency contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Relationship to applicant

How did you hear about us?

To finalize your application, please read and sign below and then click Submit.

TERMS AND CONDITIONS

Each family will be allocated $1,000 to meet with either Beecher Grogan of Bittersweet End-of-Life Doula Care or Lori Mangano of Sacred Oak Healing Services for up to 12 months. This will amount to approximately twelve hour-long sessions.
After the funds are used up, families may choose to pay out of pocket directly to Bittersweet End-of-Life Doula Care or Sacred Oak Healing Services, LLC.
Families must choose between one of the two support people, Beecher Grogan or Lori Mangano for all of their sessions. A short 30-min zoom interview with both is allowed before making a selection.
There is no restriction on the time since your child's death or geographical location for families that have lost a child to a chronic illness, disease, or disorder.
If your child died suddenly, we accept families that are within one hour distance from our headquarters in Ogunquit, ME.
Our practitioners are experienced in end-of-life and grief work, but are not licensed therapists, social workers, or psychotherapists.

CANCELLATION POLICY

If you need to cancel a session, kindly give your practitioner 24 hours notice, otherwise, Rett's Roost will need to pay for your session.

LIABILITY RELEASE

I understand, accept, and assume responsibility for any and all risks, whether or not specifically itemized herein, and I acknowledge and hereby release Rett's Roost and its directors, employees, and subcontractors, including Beecher Grogan from Bittersweet End-of-Life Doula Care LLC (Bittersweet), and Lori Mangano from Sacred Oak Healing Services LLC (Sacred Oak), from all liability and any injury arising out of any reliance upon the consultation and services provided during these sessions.

I agree that I shall defend, indemnify, and hold harmless Rett’s Roost, Bittersweet, Sacred Oak, their subsidiaries, and affiliates from and against any liabilities whatsoever, including any demand, loss, costs, or expense, and reasonable attorneys’ fees and costs of investigation, resulting from my participation in this program. In the event a claim is made against Rett’s Roost, Bittersweet, or Sacred Oak in violation of this waiver, all matters shall be subject to Mandatory Arbitration under the laws and jurisdiction of the states of Maine and New Hampshire. My participation in this program is subject to the terms of the Rett's Roost Privacy Policy.

I have read, understand, and agree to this waiver, including the Terms and Conditions and Cancellation Policy.

Signature

Date

2025 Application