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.

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* 1. Your email address

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* 2. Your name

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* 3. Your best contact number

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* 4. Please share which type of loss you have experienced.  Please check all that apply.

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* 5. Did your loss include any of the following special circumstances?  (Check all that apply.)

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* 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.

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* 7. Please let us know what other types of support resources you are currently using.  Check all that apply.

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