Sudden & Traumatic Loss Registration

Please put your first name in the box below:

Please put your last name in the box below:

Please enter your email address in the box below:

Please tell us if you or your loved one is cared for by YoloCares' hospice or palliative care staff (AGENCY) OR if you've come to us from the larger COMMUNITY:

Please select from the drop down menu the ethnic group you must closely identify with. If the drop-down choices are not sufficient, please feel free to enter your choice manually.

Our grant funders seek high levels of inclusivity not only with respect to race and ethnicity, but also gender and sexual identification. With respect for the many and diverse ways people express their identity sexually, we are asking only if you identify as heterosexual or not.

Have you experienced loss from suicide, homicide, accidental, or a sudden medical event?

Are you now or have you ever been someone who provides any kind of care for a sick or dying loved one?

In the box below, please tell us your approximate age:

Please put the city where you live in the box below:

What is the name of the county where you live?

What is your zip code?

What primary language(s) do you speak at home?

Do you live with one or more "family" member(s)?

Have you completed the Grief Support Services Consent Forms?