CompassionateReprieve

Intake Request Form

Inmate Details

Inmate Name
Facility Address

Funeral Details

Name of the decease
Decease relationship to the inmate
Funeral Date / Time
Where will the funeral service be held?
Have you requested streaming services from the church or funeral home?
Name of the point of contact at the church or funeral home
*
Messages will come from (404) 829-4343. Message frequency varies (typically 2–5 per service). Message & data rates may apply. Reply STOP to unsubscribe or HELP for assistance. See our Privacy Policy & Terms .
Address of the funeral home or church where the service will be held

Point of contact

Primary Name
*
Messages will come from (404) 829-4343. Message frequency varies (typically 2–5 per service). Message & data rates may apply. Reply STOP to unsubscribe or HELP for assistance. See our Privacy Policy & Terms .
Secondary Name
*
Messages will come from (404) 829-4343. Message frequency varies (typically 2–5 per service). Message & data rates may apply. Reply STOP to unsubscribe or HELP for assistance. See our Privacy Policy & Terms .
How did you hear about us?

Type of stream

Payment must be made in full before service; if a stream is denied, a partial refund will be issued.
One-Way Live Stream

One-Way Live Stream
Pay $150 with PayPal
Video Conference

Video Conference
Pay $300 with PayPal
By submitting this request, you confirm that you have the legal authority to act on behalf of the incarcerated individual and the deceased family member. You authorize Compassionate Reprieve to contact the correctional facility on your behalf to coordinate funeral or memorial video viewing access. We may share limited information, including the inmate’s name, funeral date, and your relationship to the inmate. Facility approval is not guaranteed. Compassionate Reprieve is not liable for any outcomes, including but not limited to denied access or facility restrictions. Your information will be used only for coordination and handled in accordance with Georgia privacy laws and applicable federal regulations. You may revoke this written authorization at any time by emailing info@compassionatereprieve.org; revocation takes effect upon receipt. This authorization is valid for 30 days and governed by the laws of the State of Georgia. By submitting this form, you agree to hold Compassionate Reprieve harmless from any claims or disputes resulting from facility decisions beyond our control.
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