Request Grief Support Services
First Name
Last Name
Email
Phone
How did you hear about us?
Please select...
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Attended an event
Friend/family member
Funeral home
Online search
Physician/Therapist
Referred by an employee
Social media
Support group directory
Used the Crisis Helpline or Hey Sam
Other
Loss Information
This information allows our facilitators to better support you in your grief journey.
Loved One's First Name
Loved One's Last Name
Who have you lost?
Mother
Father
Brother
Sister
Grandmother
Grandfather
Aunt
Uncle
Friend
Son
Daughter
Girlfriend
Boyfriend
Wife
Husband
Partner
Sibling
Family Member
Spouse
Co-Worker
When did you lose your loved one?
If you do not know the exact date, use the 1st of the month.
Do you want to share another loss with us?
Yes
No
Loved One's First Name
Loved One's Last Name
Who have you lost?
Mother
Father
Brother
Sister
Grandmother
Grandfather
Aunt
Uncle
Friend
Son
Daughter
Girlfriend
Boyfriend
Wife
Husband
Partner
Sibling
Family Member
Spouse
Co-Worker
When did you lose your loved one?
If you do not know the exact date, use the 1st of the month.
Tell us a little bit about your loss.
How would you like us to contact you?
Please have a staff member call me.
Please have a staff member email me.
I would like to sign up for a Survivor to Survivor visit.
I would like to attend SafePlace virtual groups for anyone.
I would like to attend SafePlace in-person groups for anyone.
I would like to attend SafePlace groups for parents.
I would like to attend LGBTQ+ SafePlace.
SafePlace and Survivor to Survivor visits are for suicide loss survivors only.
Our virtual Survivor to Survivor visits and SafePlace meetings utilize the Zoom platform. If you are not familiar with Zoom and need technical assistance, please let us know and we will do our best to ensure you are able to participate. Select one option below:
I need technical assistance
I do not need technical assistance
Let us know if you require any other accommodations.
We know that requesting grief support is a difficult step, and you may not be ready to have a Survivor to Survivor visit or attend SafePlace meetings right away. Can we follow up with you in 30 days?
Yes, please follow up with me in 30 days
Demographic Questions
These demographic questions help us understand the effectiveness of our marketing efforts in reaching communities at higher risk for suicide. Your answers are private and do not impact the service you receive from Samaritans.
Birthdate
Gender
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Man
Woman
Non-binary
Prefer to self-describe
Prefer not to answer
Gender
Gender Pronouns
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He/him
She/her
They/them
Other
Gender Pronouns
Please indicate your race or ethnic background:
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American Indian or Alaska Native (Not Hispanic or Latino)
Asian (Not Hispanic or Latino)
Black or African American (Not Hispanic or Latino)
Hispanic or Latino
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
White (Not Hispanic or Latino)
Two or More Races or Ethnicities
Prefer not to answer
Self Describe:
Please indicate your veteran status:
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I identify as a military veteran
I am not a veteran
Prefer not to answer
Please indicate your disability status:
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Yes, I have a disability or have a history/record of having a disability.
No, I do not have a disability or a history/record of having a disability.
Prefer not to answer
Address Information
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Address Line 2
City
State
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Postal Code
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Afghanistan
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Canada
Cape Verde
Cayman Islands
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Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
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Faroe Islands
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Finland
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French Polynesia
French Southern and Antarctic Lands
Gabon
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Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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New Caledonia
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Poland
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Reunion
Romania
Russia
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Solomon Islands
Somalia
South Africa
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Spain
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Virgin Islands ( British )
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I would like to receive text messages from Samaritans, Inc. about events, new programs, and other news.
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