Bereavement Support Form

Bereavement Support Form

Please complete and submit this form to help us get to know a little about you and the child/children you are grieving.
If you are looking for end-of-life hospital or bedside support, need someone to provide a memorial service, or need a burial gown for your child or infant, please call or text Regina directly at 540-810-0307. *If there is no answer, please leave a voicemail with your name, phone number, and reason for calling, and Regina will return your call as quickly as possible.
Name of person contacting us*

First NameLast Name
Name of person(s) looking for support if different than contact name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Best Phone Number*

Area CodePhone Number
Email*
Preferred method of contact*

TextEmailPhone call
I am interested in, check all that apply*

One-on-one visitSupport groupsRemembrance eventsOther
Name of child you are grieving

First NameLast Name
Sunrise (Date of Birth)

MonthDayYear
Sunset (Date of Death)

MonthDayYear
Gender
Name of child you are grieving

First NameLast Name
Sunrise

MonthDayYear
Sunset

MonthDayYear
Gender
Name of child you are grieving

First NameLast Name
Sunrise

MonthDayYear
Sunset

MonthDayYear
Gender
Please include my child/children in your newsletter remembrances.*

YesNo
Please add me to your newsletter mailing list. (If address and name are different than above, please list newsletter mailing name/address in the comment section below.)*

YesNo
Please share what you'd like for us to know ahead of time regarding your loss.*
Are there surviving siblings? If also requesting resources or bereavement package, please share their name(s), gender(s), and age(s). *
I would like a comfort shawl

Adult Comfort ShawlChild Comfort Shawl
I am interested in the following resources*

Parent GriefAdult Sibling GriefTeen GriefYoung Child GriefLoss by SuicidePregnancy and Infant Loss
Additional Comments
Should be Empty: