Visit Selah Carefarm - Animal Grief Therapy for Bereaved Families

Number of Client Visitors - Who will be attending your Carefarm visit?*
Up to three adult clients (spouses/partners/siblings, etc.) that may benefit from our therapy and environment are welcome to join you. These clients will engage in individual therapy, and are charged here at the same rate as your visit.
Name*
First Last
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
What is your relationship to the bereaved?*
Are you currently under psychiatric care?*
- Yes
- No
Are you currently taking any medications?*
- Yes
- No
Please list your medications*
Please provide your medications and dosages for each.
How long have you been taking your medications?*
Please let us know how long you've been taking each medication listed above.
Are you a military veteran?*
- Yes
- No
How would you identify your race or ethnicity? Select all that apply.*
- Asian or Asian Indian
- Black or African American
- Caucasian
- Hispanic, Latino or Spanish
- Pacific Islander or Native Hawaiian
- Middle Eastern or North African
- Native (American)
- Other
- Prefer not to answer
What gender do you most identify with?
Is there anything else you would like us to know?
Emergency Contact Information
In case of emergency, who should we contact?
Primary Emergency Contact*
First Last
Primary Emergency Contact's Relationship to you?
Primary Emergency Contact Phone*
Primary Emergency Contact Email*
Backup Emergency Contact*
First Last
Backup Emergency Contact's Relationship to you?
Backup Emergency Contact Phone*
Backup Emergency Contact Email*
Other Information
Your Education Level*
With whom do you live?*
Please tell us about your religious preferences*
Have you ever meditated or practiced contemplative prayer?*
- Yes
- No
Is there anything else we should know about you?*
Additional Client 1 Information
Additional Client 1 Name*
First Last
Additional Client 1 Email*
Enter Email Confirm Email
Additional Client 1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Client 1 Phone*
Is Additional Client 1 currently under psychiatric care?*
- Yes
- No
Is Additional Client 1 currently taking any medications?*
- Yes
- No
Please list Additional Client 1 medications*
Please provide Additional Client 1's medications and dosages for each.
How long has Additional Client 1 been taking their medications?*
Please let us know how long Additional Client 1 has been taking each medication listed above.
Other Information - Additional Client 1
Additional Client 1 Education Level*
With whom does Additional Client 1 live?*
Please tell us about Additional Client 1's religious preferences*
Is there anything else we should know about Additional Client 1?*
Have Additional Client 1 ever meditated or practiced contemplative prayer?*
Additional Client 2 Information
Additional Client 2 Name*
First Last
Additional Client 2 Email*
Enter Email Confirm Email
Additional Client 2 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Client 2 Phone*
Is Additional Client 2 currently under psychiatric care?*
- Yes
- No
Please list Additional Client 2 medications*
Please provide Additional Client 1's medications and dosages for each.
Is Additional Client 2 currently taking any medications?*
- Yes
- No
How long has Additional Client 2 been taking their medications?*
Please let us know how long Additional Client 2 has been taking each medication listed above.
Other Information - Additional Client 2
Additional Client 2 Education Level*
With whom does Additional Client 2 live?*
Please tell us about Additional Client 2's religious preferences*
Is there anything else we should know about Additional Client 2?*
Have Additional Client 2 ever meditated or practiced contemplative prayer?*
Additional Client 3 Information
Additional Client 3 Name*
First Last
Additional Client 3 Email*
Enter Email Confirm Email
Additional Client 3 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Client 3 Phone*
Is Additional Client 3 currently under psychiatric care?*
- Yes
- No
Please list Additional Client 3 medications*
Please provide Additional Client 3's medications and dosages for each.
Is Additional Client 3 currently taking any medications?*
- Yes
- No
How long has Additional Client 3 been taking their medications?*
Please let us know how long Additional Client 1 has been taking each medication listed above.
Other Information - Additional Client 3
Additional Client 3 Education Level*
With whom does Additional Client 3 live?*
Please tell us about Additional Client 3's religious preferences*
Is there anything else we should know about Additional Client 3?*
Have Additional Client 3 ever meditated or practiced contemplative prayer?*
Beloved's Information
Your Beloved's Name*
First Last
Your Beloved's Date Of Birth*
MM slash DD slash YYYY
Your Beloved's Date of Death*
MM slash DD slash YYYY
Your Relationship to Your Beloved*
- Your Child
- Your Parent
- Your Sibling
- Your Spouse
- Other
Please describe your relationship to "Other" person
Schedule Your Carefarm Visit
Booking Services
Select Provider*
What Day Would You Like To Visit?*

March 2023

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Please select a date from available dates above, and then select a minimum of two side-by-side, 1 Hour block times from the available times that display. (NOTE: we require and bill for a minimum one-hour two-hour visit, so please select at least two one-hour blocks (ADJACENT blocks, please!) to cover the desired duration of your visit.) Example: If you want to select a time period from 1 p.m. - 3 p.m., you would click on both the 1 p.m. - 2 p.m. and 2 p.m. - 3 p.m. time slots.
Scheduled Dates/Times
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Would you like MISS Foundation counseling along with your Carefarm visit?
- Yes
- No
Please note: your scheduled counseling will be separate from any Carefarm visiting hours booked above. We can work with you to coordinate and schedule your counseling before or after your Carefarm visit.
How many hours of counseling would you like to schedule?*
Please enter a number from 1 to 100.
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How many hours of counseling would you like to schedule?
For sliding scale fee purposes, please enter your approximate annual household income?*
Due to the high level of training required of our traumatic grief counselors, industry rates for this type of service would typically range between $150-$250 per hour. To provide more access to needed services, our rates begin at only $100 per hour.
- Below $100,000.00
- Between $100,000.00-$250,000.00
- Above $250,000.00
If you selected between $100,000.00 and $250,000.00 please provide the exact figure**
Please enter a number from 100000 to 250000.
If you selected below $100,000 please provide the exact figure*
Please enter a number from 0 to 100000.
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Additional guests?
Additional guests (up to 5) can join you at your Carefarm visit. Cost is $10 per guest, per hour. NOTE: each guest will need to provide an online guest application form and release - a link to this will be sent to you with your registration receipt.
Additional Guest Adder - Visit the Carefarm
Price: $0.00
NOTE: If for any reason there is a problem or concern with your registration, we will let you know within 72 hours.
If you have any questions in the meantime, please check our Selah Carefarm page.
Information, Consent and Waiver*
- By clicking here, I affirm that I have read, and agree to the terms of, the Information, Consent and Waiver document (button/link below)
Click here to read and agree to the Information, Consent and Waiver document
Photography Authorization*
- I would like photos taken when appropriate of my time at Selah Carefarm and consent to anonymous sharing on social media. I understand I will not be paid for any photographs.
- I would like photos taken when appropriate of my time at Selah Carefarm for private use only.
- I would not like any photos taken of my time at Selah Carefarm.
We often take photos at the Carefarm to share with others. Please indicate your preference for inclusion or exclusion in our photography above.
Coupon Code
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Final Amount
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Credit Card
Card Details
Cardholder Name

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Carefarm Rules

Carefarm Brochure

Schedule Your Carefarm Visit

Emergency Contact Information

Other Information

Additional Client 1 Information

Other Information - Additional Client 1

Additional Client 2 Information

Other Information - Additional Client 2

Additional Client 3 Information

Other Information - Additional Client 3

Beloved's Information

Schedule Your Carefarm Visit

March 2023

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