Grief Support Inquiry Form

Fill out the information below

This form is intended for families or individuals inquiring about grief support for themselves. We ask that only those interested in support complete this form and not counselors, social workers or others who wish to refer a family to Imagine. If you know of someone who might benefit from Imagine’s programs, please share the link to this page with them. They can also contact us at 908-264-3100.

This form is not appropriate for unsolicited marketing and business inquiries and requests. If you would like to inquire about partnerships, please contact community@imaginenj.org.

Name(Required)
First Last

Email(Required)
Enter Email Confirm Email

Phone(Required)

Address(Required)
Street Address City State / Province / Region ZIP / Postal Code Country

Which Location Works Best For You?(Required)
Mountainside
Newark
Virtual

Please check the box if you are interested in receiving information about our new virtual suicide loss support groups.
Yes, I'm interested in learning about virtual suicide loss support groups.

PREFERRED TIMES TO REACH YOU(Required)

9:00 AM - 11:00 AM

12:00 PM - 4:00 PM

AGE OF FAMILY MEMBERS(Required)

3-18 years old

19-30 years old

Caregiver, who lost a child who is 0-25 years old

HOW DID YOU HEAR ABOUT IMAGINE?(Required)

HOW CAN WE SUPPORT YOU?(Required)

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Si habla español y desea solicitar asistencia, utilice este formulario y un miembro de nuestro personal que hable español se comunicará con usted.