Intake Form

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Grief Coaching Intake Form

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Tell me about yourself.

This form is to get us started. Answer as little or as much as you like.

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Name(Required)
Address
MM slash DD slash YYYY
Waiver(Required)

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Counselors are responsible for their participants’ welfare and take reasonable precautions to avoid causing emotional, physical, or social harm to participants.

I/We understand that I may be photographed while participating in this activity. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the activity holders, producers, sponsors, organizers, and assigns.

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“ He whispered,

My precious child, I love you and will never leave you.

Never, ever, during your trials and testings.
When you saw only one set of footprints, It was then that I carried you.

— Footprints In The Sand

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