Contact Us - Service Engagement Form

Employer Information:

Company Name*

Person submitting this form*

Job Title

Relationship to Bereaved Employee

Email*

Phone*

Employee Information

Employee Name*

Job title

Work Email*

Personal Email

Cell or Home Phone Number

Anticipated return to work date

Years of employment

Estimated Funeral Date (if applicable)

Cause of death

Approximate Age of Child

Preference on who reaches out first to affected employee to notify them that this service is being offered to them:*

Hope Works Here/Faith’s Lodge
My Company/Affected Employees Manager

Please list any specific concerns you have regarding your employee and/or the work team that you’d want the transition coach to be aware of and/or address:

An invoice will be sent for your Service Engagement fee upon receiving the Service Engagement Form.

Employer understands that engagement in the Hope Works program for this employee is meant to minimize the economic impact of child loss grief or medically complex diagnosis of a child the workplace. Faith’s Lodge offers no guarantees related to economic savings or job performance. Faith’s Lodge makes no guarantees regarding benefits obtained by employee or employer from the program and the elements therein. The service engagement fee allows employers access to the program for one specific employee starting on the date that payment is received by Faith’s Lodge. Service Engagement fees are non-refundable if the service is not engaged by the employee. Faith’s Lodge, the assigned transition coach or any of their affiliates are not liable for any damages or losses related any employee’s grief or services provided. Employer releases Faith’s Lodge from all liability related to the program.

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