Family Support Request Form
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 wishes for your child.

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. We will be working directly with you to be sure you are receiving the support needed at this time.

FOR IMMEDIATE SUPPORT SERVICES:
>YOU WILL RECEIVE AN EMAIL FROM HALOS WITHIN 24 HOURS OF SUBMISSION OF THE COMPLETED FORM. THE EMAIL WILL EXPLAIN HOW WE WILL PROCEED IN ASSISTING YOU.

>UPON VIEWING OUR EMAIL, YOU MUST CONTACT US VIA PHONE (1-866-411-4256) BEFORE ANY ARRANGEMENTS WITH A FUNERAL HOME ARE MADE TO ENSURE WE ARE ABLE TO PROVIDE THE RESOURCES YOU ARE REQUESTING.

PART I - FAMILY INFORMATION
PLEASE COMPLETE THIS SECTION TO THE BEST OF YOUR ABILITY
Today's Date *
MM
/
DD
/
YYYY
Parent 1 Full Name *
Your answer
Parent 2 Full Name *
Your answer
Parent 1 Address including City, State and Zip Code *
Your answer
Parent 2 Address including City, State and Zip Code (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 or Children's Full Name(s) *
Your answer
Child's Gender *
Required
Child's Date of Birth
MM
/
DD
/
YYYY
Child's Date of Death
MM
/
DD
/
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 and Email of an individual (Parent, Friend) if any, who may help you in facilitating any communication with Halos
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service