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Companions Program Interest Form

This questionnaire will assist the H.E.A.R.T.strings Bereavement Office in matching you with a peer mentor.  Please answer as many questions as you can.  One of us will reach out to you soon.  Please note that we take great care in matching you with a suitable peer companion.  If you have not heard from us within a week after completing the form, please call our office at 404-851-8177.
1.Your email address
2.Your name
3.Your best contact number
4.Please share which type of loss you have experienced.  Please check all that apply.
5.Did your loss include any of the following special circumstances?  (Check all that apply.)
6.What area of metro Atlanta do you live?  If at all possible, we will consider matching you with a companion who lives close to you.  This can not be guaranteed, but will help us during the matching process.
7.Please let us know what other types of support resources you are currently using.  Check all that apply.