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Caring & Coping Support Group Registration
Registration is free and this form allows us to collect attendance for the meeting. All information is confidential. By completing this form, you agree to receive email communication regarding the support group schedule.
1.
Your email address
2.
Your first and last name
3.
Your mailing address (street name, city, state and zip code)
4.
Your best contact number
5.
Name of partner/ support person (if participating)
6.
How did you find our support group?
I was a patient at Northside Hospital.
I was not a patient at Northside Hospital, but received your information from the hospital where I was a patient.
My physician gave me your information.
Other (please specify)
7.
Please share which type of loss you have experienced? Check all that apply.
1st trimester loss (conception-12 weeks)
2nd trimester loss (13 weeks-27 weeks)
3rd trimester loss (28 weeks-term)
NICU loss
SIDS loss
Loss of a multiple with a surviving baby
Other (please specify)
8.
Did your loss include any of the following special circumstances? Check all that apply.
Ectopic pregnancy
Loss of one or more multiples
Medical termination
N/A
Other (please specify)
9.
Caring & Coping Support Group Ground Rules:
1. Sessions begin at 7pm. Access to the meeting link will close at 7:15pm.
2. Sessions are private and confidential: Please do not share information from sessions with anyone outside the group. In order to ensure confidentiality, we are requiring participants to use the video option so that everyone in the group can see each other and so that all can be confident in knowing who is participating.
3. You must be in a private and quiet location to participate. You can not log in from moving cars or public locations. If you are at home, you must be in a quiet area. In particular, if you have children at home, out of an abundance of respect for grievers, please make sure they can not be heard by group members.
4. Respect the experience of others: everyone brings a different story and journey to the group. All are welcome, regardless of when you lost your baby.
5. Your phone must be turned off during the group session. Screen shots and taking video during the session are prohibited.
6. Do not eat during the session. Have water on hand, if needed.
7. In order to make sure everyone has an opportunity to participate and share, please have a white piece of paper (index card size) to hold up. This will ensure that everyone has the chance to participate.
8. Please wear appropriate attire: no attire suited for sleeping or lounging by the pool.
**These guidelines are subject to change.
I have read and understand the Support Group Guidelines & Ground Rules.
Yes, I have read and understand the Support Group Guidelines & Ground Rules.