Client Release Form

FHGR, Inc. is a 501 (c)(3) non-profit organization with a mission to provide guidance and compassionate support to people who have suffered the sudden loss of a loved one. We are not licensed psychologists or psychiatrists and our training comes from our own experiences and years of helping others in similar situations. Our goal is to guide you through honoring your loved one and to provide grief counseling for the days that follow. You are under no obligation to work with us. By submitting this form, you release FHGR, Inc., staff and volunteers from any legal liability including but not limited to financial or contractual liabilities which may arise in the context of your working with our organization.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Emergency Contact*
First Last
Emergency Contact Phone*
Your Email*
Name of Deceased*
Your Relationship to Deceased*
Date of Loss*
MM slash DD slash YYYY
May we contact you via phone and email?*
- Yes
- No
How did you hear about us?
Signature*
Date*
MM slash DD slash YYYY