Support Inquiry/Request form

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PLEASE READ BEFORE COMPLETING FORM:

Three Little Birds is a small, volunteer run non-profit project focusing on the needs of families in the Philadelphia/South Jersey region. DUE TO AN OVERWHELMING RESPONSE FOR SUPPORT, WE CAN ONLY RESPOND TO INQUIRIES FROM FAMILIES LOCATED WITHIN 50 MILES OF PHILADELPHIA.

If you have found us but live outside the Philadelphia/South Jersey you can still find resources helpful to you on our web page. Unfortunately, we cannot provide bereavement doula services outside of our region. If you are in need of an elevated level of support, click this link to find a bereavement doula in your region who can support you with more local resources and helpful information. https://stillbirthday.com/find-doula/

Please complete this brief survey regarding the support you need and the appropriate Three Little Birds representative will be in contact with you ASAP.

Email *

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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