Contact Us - Join as an Employee

Employee Service Option Form [FINAL]

Your Employer Cares! They have engaged the Hope Works Here program to guide your transition back to work.
Hope Works Here includes:
1. Three (3) Transition Coach visits (A transition coach is a clinical mental health professional specifically chosen by Faith’s Lodge who specializes in childhood illness or death.)
  - First visit: one-on-one with affected employee PRIOR to employee’s return to work
  - Second visit: transition coach meets with team at the workplace PRIOR to employee return
  - Third visit: one-on-one with affected employee AFTER employee returns to work
2. A certificate for a long weekend stay at Faith’s Lodge - faithslodge.org
3. Resources specific to the child’s cause of death or medically complex condition.
  - Resources for employer to understand how this impacts the workplace
  - Resources for employer to give to the employee that are specific to the loss or medically complex diagnosis
Do you want to avail of this Service?
- Yes I want to engage (please fill out rest of form & submit)
- No, I do not wish to engage (please sign/submit)
Name*
Address*
Address Suite or Apt City State ZIP Code
Phone*
Email*
Employer*
Job title
Child’s Name*
Child’s DOB*
MM slash DD slash YYYY
Child’s DOD (if applicable)
MM slash DD slash YYYY
Cause of death
Cause of death
Anticipated return to work date*
MM slash DD slash YYYY
Anticipated funeral date (if applicable)
MM slash DD slash YYYY
Years of employment
Please list any specific concerns you have regarding returning to work?

Join as an Employee

Employee Service Option Form [FINAL]

Hope Works Here includes: