Keys of Hope Foundation Registration
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*Please Note*
Group meetings are biweekly on Thursdays 6:30 - 8:30pm each session. 
Which Cohort are you registering for? *
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Full Name
Address
Phone (     )          -
Personal Information
Email
Date of Birth
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Current Age
Sharing Your Experience
Please check any that may apply to your pregnancy loss experience:
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When did your loss/losses occur?
Do you have a diagnosis of either of the following? *
Physical and Emotional Status: Which of the following emotions and behaviors have you felt or demonstrated since the loss of your baby?
Please check any that may apply for CURRENT behaviors.
Please check any that may apply for PAST behaviors.
Have you received any professional counseling since the loss of your baby?(Psychiatrist, psychologist, social worker, pastoral counseling, peer support etc.)
If so, Please indicate the type of counseling you’ve received and the length of service.
Is there anything we should know about your physical or emotional well being prior to group sessions?
What has been the most difficult part of your life after the loss?
Are there any specific topics you’d like to discuss during this support group cohort?
What are you hoping to gain from this support group cohort?
Each cohort consist of six bi-weekly meetings (Thursdays 6:30pm-8:30pm) over a 12 week period, with a follow-up meeting four to six weeks following the program completion.
Are you willing to commit to completing the FULL session? *
Have you been in close contact with or cared for someone with COVID-19 in the last 14 days? *
Address:  5090 State Suite 104B Saginaw, MI 48603 Professional Arts Building (next door to Taco Bell)
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