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Complete the following form if you are interested in receiving more information about our services. Please note, the adult individual (or the parent/caregiver of youth) interested in services must complete the form.

Due to an increase in requests, please allow 48-72 business hours for our staff to return your call. We encourage you to call or come to the group 30 minutes before a group begins if you are interested in attending that same day.

The Center is NOT an emergency/crisis facility. If you or someone you know is suicidal or homicidal or in any emergency situation, call 911 or go to the nearest hospital emergency room. You can also call the Center for Health Care Services 24-hour Crisis Hotline at (1-800-316-9241 or 210-223-7233); United Way by dialing 211; or Suicide Prevention Lifeline at (1-800-273-8255) available 24 hours a day.

"*" indicates required fields

Name*

First Last

Email*

Phone*

How did you find us?*

Self Referral

Referral from Friend, Family, Neighbor, etc.

Referral from an Agency

Therapist

Kindful Hospice

Best Time to Call*

Anytime

Morning (9-noon)

Early Afternoon (noon-3)

Late Afternoon (3-5)

Can we leave a voicemail message?*

Yes

I’m interested in*

Speaking to someone about my loss

Adult support groups

Children/Teen support groups

School-based services

Referring a family

Referring a child/teen

Education/training

I live in

Travis County

Williamson County

Hays County

Other Texas County

Outside Texas

Brief description of the death loss - include: who died, date of death, cause of death, any support systems, any services, and if you are inquiring about services for someone other than yourself, their name and age.*

Maximum characters: 200

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