Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Father/Partner's Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Date of Loss *

MM

DD

YYYY

Do you have other children? *

Yes

No

Emergency Contact #1 *

First Name

Last Name

Emergency Contact #1 *

Phone

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Emergency Contact #2 *

Phone

(###)

###

####

Have you received counseling? Minimum 5 sessions? *

Yes

No

Interested in the following: *

Please check any/all that apply.

Fishing

Learning to surf

Kayaking

Paddleboarding

Beginners Yoga

Advanced Yoga

Biking

Walks on the beach

Form Completed By: *

First Name

Last Name

I confirm I do not require support for any of the following: Co-occurring drug and alcohol related issues; Eating disorders; Persistent mania; Cognitive challenges; Non-compliance with prescribed medications; Actively suicidal; History of violence or exhibits violent tendencies; I also understand The Finley Project would not be an appropriate program for an individual who requires 24-hour visual monitoring or inpatient care. *

I agree

I agree to the following: 1) I am more than one year after loss (must be 12 months post loss). 2) I have attended/have seen a licensed mental health counselor for a minimum of 5 sessions. 3) I am a minimum age of 18 for program participation. 4) I have a desire to explore and move through grief into new dreams/opportunities. *

I agree