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* 1. Please provide the following information:

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* 2. Please briefly describe your experience with pregnancy/infant loss:

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* 3. Please provide the date(s) of your loss(es) and name of baby/babies (if named):

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* 4. Do you have other children?

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* 5. Have you attended a HAND support group?

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* 6. If so, which chapter?

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* 7. What topics or concerns would you like to discuss with your peer support volunteer?

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* 8. Do you have any special concerns you would like your peer support volunteer to know about?

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* 9. How would you like to communicate with your peer support volunteer?

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