Name *

First Name

Last Name

Birthdate

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Partner's Name

First Name

Last Name

Type of Loss(es)

Check all that apply

Early loss

Second trimester loss

Third trimester loss

Infant/neonatal death

Grieving father

Grieving mother

Grieving partner

Other

How did you hear about Empty Arms?

Hospital (Emergency Dept)

Hospital (Obstetrics)

Hospital (Spiritual Care)

Media

Obstetrics/Fertility Clinic

Previous experience

Web search

Agreement *

+ I understand that support provided by Empty Arms is peer support, and not professional or medical help. + I understand that, if at any time, I decide that I no longer wish to maintain contact with the peer support volunteer, I may send an email to info@emptyarmspls.com indicating as much. + I understand that contact between myself and the Empty Arms volunteer will remain through email, unless both parties agree to otherwise. + I understand that information shared with Empty Arms and the volunteer will be kept confidential, unless it is believed that I am a danger to myself or someone else.

I agree

I do not agree