Client Release Form
FHGR, Inc. is a 501 (c)(3) non-profit organization with a mission to provide compassionate guidance and support to people who have suffered the sudden loss of a loved one. We are not licensed psychologists or psychiatrists and our training comes from our own experiences and years of helping others in similar situations. Our goal is to guide you in honoring your loved one and provide grief mentoring in the days that follow. You are under no obligation to work with us. By submitting this form, you release FHGR, Inc., staff and volunteers from any legal liability including but not limited to financial or contractual liabilities which may arise in the context of your working with our organization. If at any time we believe you may be at risk of harming yourself or others, you authorize FHGR, Inc., its staff and volunteers to seek appropriate outside assistance, including contacting emergency services or a third party, and you agree that FHGR, Inc. shall not be held liable for such actions taken in good faith.
Name
*
First Name
Last Name
Your Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Rather not say
Ethnicity
Black/African American
Hispanic
Caucasian/White
Other
Emergency Contact
*
First Name
Last Name
Relationship
(Uncle, Parent, Sister, etc.)
Your Birth Date
-
Month
-
Day
Year
Anniversary Date
-
Month
-
Day
Year
(Wedding, if applicable)
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Deceased
*
First Name
Last Name
Love One's Birthday
-
Month
-
Day
Year
Your Relationship to Deceased
*
Such as Daughter, Brother, Husband, etc.
Date of Loss
*
-
Month
-
Day
Year
May We Contact You via Phone and Email?
*
Yes
No
How Did You Hear About Us?
Signature
*
Continue
Continue
Should be Empty: