Companions Program Interest Form

This questionnaire will assist the H.E.A.R.T.strings Bereavement Office in matching you with a peer mentor. Please answer as many questions as you can. One of us will reach out to you soon. Please note that we take great care in matching you with a suitable peer companion. If you have not heard from us within a week after completing the form, please call our office at 404-851-8177.

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* 1. Your email address

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* 2. Your name

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* 3. Your best contact number

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* 4. Please share which type of loss you have experienced. Please check all that apply.

1st trimester (conception-12 weeks)

2nd trimester (13 weeks-27 weeks)

3rd trimester (28 weeks-term)

NICU loss

SIDS loss

Other (please specify)

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* 5. Did your loss include any of the following special circumstances? (Check all that apply.)

Ectopic pregnancy

Loss of one or more multiples

Medical termination

Not applicable

Other (please specify)

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* 6. What area of metro Atlanta do you live? If at all possible, we will consider matching you with a companion who lives close to you. This can not be guaranteed, but will help us during the matching process.

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* 7. Please let us know what other types of support resources you are currently using. Check all that apply.

Support group

Private counseling

Other (please specify)