Support Inquiry/Request form
Please complete this brief survey regarding the support you need and the appropriate Three Little Birds representative will be in contact with you within 12 hours.
* Required
Email address
*
Your email
Name
*
Your answer
Phone number that receives text messages
*
Your answer
Location: City, State needed only
*
Your answer
Please check the boxes that apply
*
I am a parent experiencing pregnancy/infant loss
I am a family member or friend supporting someone through pregnancy/infant loss
I just received a life-limiting or uncertain fetal diagnosis
Other:
Required
I am seeking the following support: (check all that apply)
*
I would like to speak to a bereavement doula
I am in need of financial support/resources
I would like to be connected to another parent who has walked a similar journey
I'd like some information on what options are available to me to consider
I'm looking for local support groups or care providers
Other:
Required
My preferred method of contact is
*
Text message
Email
Phone call
Video chat/Zoom call
I'm looking for local support groups or care providers
In person
Via a family member or friend that I have asked to support me - Please provide their contact information in Other
Other:
Required
Please answer the following questions (if you are comfortable) so we can put you in contact with the right person:
I am experiencing a miscarriage in the first trimester
I am experiencing a miscarriage in the second trimester
I am experiencing a stillbirth in the second trimester
I am experiencing a stillbirth in the third trimester
My baby passed away during birth
My baby passed away in the NICU
My baby passed away from SIDS/SUIDS
I am in need of LGBTQ specific support
I am in need of support for dad/non birthing parent
I am unsure of my disposition options and would like more information
I am pregnant after experiencing a loss and need support/resources
I am seeking support for a sibling grieving the loss of our pregnancy/baby
Other:
Any other support you are in need of?
Your answer
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