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Pet Loss eBook
Intake, Disclosure and Consent Form Single Session
Name
(Required)
Address
(Required)
Phone Home
(Required)
Phone Work
Phone Mobile
Email
(Required)
Preferred Contact Method
(Required)
Phone work
Phone Home
Phone Mobile
Email
May I leave a message, or text message via your preferred contact method above if required?
(Required)
Yes
No
Would you like to be notified via email of upcoming Events e.g. Pet Memory Walk, Online Pet Loss Support Groups etc.
(Required)
Yes
No
How would you prefer to talk with Vicky
(Required)
Telephone
Zoom
What days/times are you available?
(Required)
Pet's Name
(Required)
Pet's Age
(Required)
Type of Animal
(Required)
Date of Loss (if applicable):
(Required)
DD slash MM slash YYYY
Length of relationship with pet:
(Required)
Circumstances of loss (if applicable): e.g. accident, euthanasia, chronic illness, old age, aggressive sudden illness etc.
(Required)
If applicable, has your pet been given a diagnosis by a vet? If so, please provide some details here:
(Required)
Are you experiencing any of the following?
Lonliness
Anger
Guilt/Regret
Depression
Eating/Sleep Disturbances
Fatigue
Suicidal Thoughts
Other
Do you feel you are in any level of danger, to yourself or others?
(Required)
Yes
No
Maybe
Is there anything specific you would like to address in sessions with Vicky?
(Required)
Do you have any additional information you would like me to know?
(Required)
Lastly, where did you hear about my specific pet loss support?
(Required)
👉 Tap here to view and read the Disclosure and Consent Form (PDF)
Signature (I have read and understood the D&C Form)
(Required)
Clear
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