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*

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.

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*

Your Beloved's Date of Death*

Your Relationship to Your Beloved*

Please describe your relationship to "Other" person

Schedule Your Carefarm Visit

Booking Services

Select Provider*

What Day Would You Like To Visit?*

July 2021

Sun	Mon	Tue	Wed	Thu	Fri	Sat
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4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30	31

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 half-hour one 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

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.

Base Counseling at the Carefarm*

Price: $50.00

What is your approximate annual household income?*

Please enter a number greater than or equal to 45000.

Please enter a number greater than or equal to 45000. (NOTE: if your annual household income is less than $45,000, simply enter $45,000 for our minimum rate calculations.

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.

Total

$0.00

Credit Card

Card Details

Cardholder Name

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

July 2021

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