Grief Support Application Form

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Hi love,

I would first like to thank you for being brave enough to accept support as you go on your grief journey. being that It's so important to feel safe with the person you unpack it all with, it would be my honor to not only support you and walk alongside you but also meet you and your heart exactly where you are at.

Grief can be so Isolating but no matter where you are in your grief, you are not alone. Nothing is wrong with you and are not crazy. You are grieving the loss of someone you love with your whole heart and that...sigh...is beyond devastating.

Anything you share with me is confidential. These questions are for me to have an idea of where you are in your grief journey and how I can best support you.

Name *

E-mail *

Phone number (best number to contact you) *

Where do you live? (City, State and Country for time zone reference) *

Where are you in your grief journey? *

0 to 6 months

6 months to 1 year

1 year to 2 years

3 years to 5 years

5 years plus

What are some reasons why you are seeking support? *

What are you struggling with the most? *

At this time, what best describes how you feel *

I am in tremendous pain and don't know how to go on

I am suffocating in pain, completely overwhelmed and don't know how to handle so many different emotions

Though I struggle some days, I am coping better with my grief and I am ready to go on a healing journey, work on my self and rebuild my life while embracing my loss

I have support from some friends and family but looking for community and to connect with others going through a loss

I think I am ready to date but conflicted with so many mixed emotions and the parts of my grief that are coming up

I am in a relationship/re-married and need help navigating new layers of my grief

Please tell me a little bit about your loss and when your person passed away *

How have you been coping with your loss? What has been helpful? *

Do you have a comment or question for me? *

Thank you so much for your time, I look forward to speaking with you!

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