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HAND of the Bay Area - Peer Support Request Form
Complete this form to be matched with a volunteer for one-on-one support. To register for support groups, please email
meetings@handsupport.org
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* Required
Email
*
Your email
Name
*
Your answer
Phone Number
Your answer
Mailing Address
Your answer
City/State/Zip
Your answer
Please briefly describe your experience with pregnancy/infant loss.
Your answer
If you have experienced a pregnancy/infant loss, please provide the date(s) of your loss(es) and name of baby/babies (if named).
Your answer
Do you have other children?
Yes
No
Clear selection
If yes, names and ages.
Your answer
Have you attended a HAND support group?
(Support group attendance is not required to receive peer support)
Yes
No
Clear selection
If so, which chapter?
North Bay (San Rafael)
San Francisco
San Mateo
Santa Cruz
Other:
What topics or concerns would you like to discuss with your peer support volunteer?
Your answer
Do you have any special concerns you would like your peer support volunteer to know about?
Your answer
How would you like to communicate with your peer support volunteer?
Phone
Email
In person
If you are new to HAND, would you like to be added to our email list to receive our quarterly newsletter and occasional notifications about HAND activities?
Yes
No
Clear selection
Submit
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