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.

Email address *

Name *

Phone number that receives text messages *

Location: City, State needed only *

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

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?

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