Mutual Aid Mourning and Healing Request for Support

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear friend,

If you are filling out this form, someone close to you has passed. With all the love in our hearts, we want to offer our deepest condolences and witness. There are no words to adequately comfort you. However, it is our humble and sincere hope that we might connect you with someone who can help facilitate some comfort and ease in your time of sorrow.

We are a group of Chicago-based organizers gathering a list of clergy members, death midwives/doulas, therapists, social workers, and healers who are here to offer some support by phone or video conferencing.

Please fill out the form below and tell us as much as you can about the support you are seeking. Within 24-hours, one of us will be in touch to connect you with someone or update you on the status of your request.

Please note that your information will not be shared outside this organizing team.
If you are a caregiver looking to volunteer your services, please email mutualaidmourning@gmail.com

In Solidarity,

Kelly Hayes, Tanuja Jagernauth, Heather Lynn, Nina D'Angier, Ashon Crawley, and Rabbi Brant Rosen.

Your name:

Email address: *

Phone number: (if you are seeking support via phone)

Your preferred method(s) of communication: (check all that apply) *

phone call

text

video conference

Required

With whom would you like to be connected? *

Someone who can officiate a remote memorial service or funeral

A clergy member

A death midwife or death doula

A therapist

A social worker

A Reiki practitioner

Someone else (Please tell us more in the next section.)

Required

Please tell us a little about the kind of support you are seeking: *

Is there anything else you would like us to know?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms