H.E.A.R.T.strings Palliative Care Program Survey

The H.E.A.R.T.strings Perinatal Palliative Care Program is a support program for families who have been given a life-limiting diagnosis for their unborn child. Please complete this questionnaire so that we can better understand your story. One of us will reach out in the next few days to talk to you more in detail about the program and about setting up a time to meet with our perinatal palliative care team. If you have not heard from us within 5 days after submitting this form, please call our office at 404-851-8177.

1.Your email address

2.Your name

3.Your best contact number

4.Your street name/ number (mailing address); city/ state; zip code

5.What is your due date?

6.Where will you deliver?

Northside Hospital Atlanta

Northside Hospital Cherokee

Northside Hospital Forsyth

Northside Hospital Gwinnett

I am not delivering at Northside Hospital. **Please note that if you are not delivering at Northside Hospital, we can still send you support resources and you can participate in our support groups, peer companion program, etc. However, we will be unable to meet with you to formulate a birth plan.

7.Tell us about your physician team. What are the names of your obstetrician and your perinatologist (maternal-fetal specialist)?

9.Are you expecting a boy or a girl?

Boy

Girl

We are not finding out the gender.

10.Have you met with a neonatologist (baby specialist) to better understand your baby's diagnosis? This is a consult that is typically scheduled by your maternal specialist/ perinatologist.

Yes

I am not sure.