* 1. Contact Info

* 2. Agency/Department represented

* 4. Please list the number of people that you wish to send to this training. (Individuals use “1” for yourself)

* 5. Are you willing to travel outside of your region for this class?

* 6. Are you willing to participate in grief counseling at the agency, department, or regional level?

* 7. Are you currently involved in grief counseling?