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Pet Loss Support Registration
Contact Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Phone
*
Pet's Name
Please share anything you would like to about your pet
Species
select one
Cat
Dog
Bunny
Other
How can we best support you?
Please choose Zoom/Group meeting or private consultation. Due to increased interest in group meetings, each person may attend up to 3 Zoom Group sessions in a year. If you want/need more counseling assistance, you may select "Private phone call" to continue your counseling. - NOTE: As of April 2023, Zoom Groups are temporarily unavailable. We will resume Zoom Groups as soon as possible.
Private Phone Call
How did you hear about us?
Emergency Contact Name
Emergency Contact Phone
BirchBark sends out email newsletters. Would you like to receive our newsletters?
*
Yes
No
Optional Information (confidential)
This information helps us understand our demographics, and is purely for data gathering. Your private information will not be shared.
Gender Identification
select one
Female
Male
Binary
Other
Prefer not to state
Ethnicity
select one
Asian American
Black/African American
Caucasian
Hawaiian/Pacific Islander
Hispanic/Latino
Mixed
Native American/Alaskan
Other
Annual Household Income
select one
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 or more
Age
select one
17 or younger
18 to 29
30 to 49
49 to 64
65+
Education
select one
High School/GED/
Some College
Bachelors Degree
Masters Degree
PhD
Other
Single-line input