Get Support - Make Justice Healing

Get Support

*Children under 18 are required to have a parent or guardian fill out.

Service Intake Form

Preliminary Service Intake Form

Name of person completing form(Required)

First Last

Email(Required)

Date of birth(Required)

Child's name(Required)

First Last

Name of child applying to receive service.

Relationship to child(Required)

Contact number(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Child's gender

Female

Male

Prefer Not To Say

Other

Child's current grade in school

Child's extracurricular activites

Parental loss experienced by child(Required)

Yes

Has the child lost a parent to gun homicide?

Which parent(s)(Required)

Which parent is no longer with us?

Services you are seeking(Required)

Describe the services you wish to receive and why you are seeking them.

How intense is the child's emotional distress on a scale of 1-10

1-Mild, 10-Severe

Current legal caregiver/guardian(Required)

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Service Intake Form

Make Justice Healing Incorporated is a 501(c)3 organization. All donations are tax-deductible as permitted by law. Our tax ID number is 92-2946125.

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