Healing Hearts: support for bereaved families with email pen pal

Please complete all the fields below If you would like to be included on our Pen Pal pages. Use the "TAB" key to move between fields. If you use the 'enter' key you may accidentally submit the form before you're finished. We will only publish the information you provide in this form. If you would like us to include additional information, please indicate it in the comments below. Thank you.

If you have any questions, please feel free to contact us at penpal@healingheart.net.

If your family is currently listed as a pen pal, and you no longer wish to be included, just use the comments field to indicate that you would like your family removed.

Name

Relationship to Person who died

Name of Person who died

Gender Boy Girl

Person's Birth date:

Date of Death:

Cause of Death

Please select the categories that most closely matches your circumstances.
Age/Relationship Category:

Cause of Death Category:

Comments

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