Grief Support Session Intake Form
Please complete this form to help us understand your needs and support your healing journey.
Disclaimer:
These sessions provide support, encouragement, and guidance, and are not a substitute for licensed mental health therapy, medical care, or emergency/crisis services.
Client Information
Full Name
*
First Name
Last Name
Preferred Name (optional)
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City & State
*
Preferred Method of Contact
*
Phone
Email
Text Message
Emergency Contact
Emergency Contact Name
*
Relationship to You
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Grief Journey
Type(s) of grief you are currently experiencing (select all that apply):
*
Death of a loved one
Divorce or relationship loss
Family estrangement
Friendship loss
Job or career loss
Health-related loss
Pregnancy or infant loss
Caregiver grief
Pet loss
Major life transition
Other
Brief description of your loss or grief experience
*
How long have you been experiencing this grief?
*
Less than 3 months
3–6 months
6–12 months
1–2 years
More than 2 years
Session Goals
What prompted you to seek support at this time?
*
What do you hope to gain from one-on-one support sessions?
*
Additional Information
Is there anything else you would like our team to know?
Acknowledgment
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: