Coping With Bereavement Intake Form (Age 18+)

Your name *

Email address *

Phone number

Birthdate

Address

How did you hear about us?

Sharing About Your Person

The next section of this form will ask you to share about the person who has died. We understand that this may be a difficult and emotional task, and we deeply appreciate you taking the time to tell us about your person. Your story matters, and we are here to honour it with care and understanding.

Name of Deceased *

Relationship to You *

Cause of Death

Date of Death *

Contact Availability for an Interview Time with Pastor Shirley

In this section, we ask for your availability to ensure we can reach you at the most convenient times. We also want to acknowledge the limits of our support and ensure you understand the type of services we offer. Your understanding helps us provide the best care possible within our resources.

Please note: *

I acknowledge that the support offered is peer support. It is not professional counselling, therapy, or crisis intervention. Our peer supporters come with their own lived experiences of loss and are here to walk alongside you with compassion and understanding. While we may not always be able to match you based on specific types of loss or life circumstances, we will do our best to understand your needs and offer support with the resources available to us.

Please note: *

I acknowledge that my support sessions may be held with and/or facilitated by a staff member, a volunteer or a student.

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