Family Support Guide Questionnaire
We understand the heartache and pain you are in at this time, and want you to know that we are here to assist and support you through all the decisions you must make, regarding your wishes for your child. We would like to suggest that you make a list of any questions, concerns, desires and plans you may have pertaining to you and your child’s care, This list along with the completed Support Guide that will be sent to you via email, should be given to your Halos Support Advocate to help us best assist you through this planning process.

We ask that you please complete as much of this form as you are able to at this time, so that we are able to support you before any financial decisions have been made. You or someone you choose (family member, friend) as your liaison, will be working directly with your Support Advocate, to be sure you are receiving the support and care needed at this time.

PART I - FAMILY INFORMATION
PLEASE COMPLETE THIS SECTION TO THE BEST OF YOUR ABILITY
Today's Date *
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Parent 1 Full Name *
Your answer
Parent 2 Full Name *
Your answer
Parent 1 Address *
Your answer
Parent 2 Address (if different from above) *
Your answer
Parent 1 Phone Number *
Your answer
Parent 2 Phone Number *
Your answer
Parents 1 Email *
Your answer
Parents 2 Email *
Your answer
Child's Full Name *
Your answer
Child's Gender *
Child's Date of Birth *
MM
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DD
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YYYY
Child's Date of Death *
MM
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DD
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YYYY
Cause(s) of Death: *
Required
If you have already had a funeral/memorial service for your child, and are contacting us, please move to PART II
Servicing Hospital, Funeral Home or Medical Examiner
Your answer
Have you already spoken to OR chosen a funeral home?
If you have spoken to OR chosen a funeral home, which funeral home is that?
Your answer
Name & Phone Number of person making arrangements and relationship to child
Your answer
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