Companions Volunteer Mentor Interest Form

Please Note: This form is for those seeking to mentor someone that has recently experienced a perinatal loss.

This questionnaire will assist the H.E.A.R.T.strings Perinatal Bereavement & Palliative Care Office in identifying candidates for our Companions Peer mentor program. Mentors must be at least one year out following the loss of their baby and will complete a training program with the Northside Hospital-Atlanta Auxiliary. Please answer as many questions as you can. If you have not heard from us within a week of completing the form, please call our office at 404-851-8177. Thank you for your interest in this special program.

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* 1. Your email address

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* 2. Your first & last name

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* 3. Your best contact number

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* 4. Please share which type of loss you have experienced. Check all that apply.

First trimester (conception-12 weeks)

Second trimester (13-27 weeks)

Third trimester (28 weeks-term)

NICU loss

SIDS loss

Loss of a multiple with surviving baby(ies)

Other (please specify)

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* 5. Did your loss include any of the following special circumstances? Check all that apply.

Ectopic pregnancy

Loss of one or more multiples

Medical termination

Not applicable

Other (please specify)

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* 6. What area of metro Atlanta do you live? If at all possible, we will consider matching you with a peer who lives close to you. This is not guaranteed, but will help us with the matching process.

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* 7. Did your loss occur at least one year or more from the time you are submitting this interest form?

Yes

Companions Volunteer Mentor Interest Form

Question Title

* 1. Your email address

Question Title

* 2. Your first & last name

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* 3. Your best contact number

Question Title

* 4. Please share which type of loss you have experienced. Check all that apply.

Question Title

* 5. Did your loss include any of the following special circumstances? Check all that apply.

Question Title

* 6. What area of metro Atlanta do you live? If at all possible, we will consider matching you with a peer who lives close to you. This is not guaranteed, but will help us with the matching process.

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* 7. Did your loss occur at least one year or more from the time you are submitting this interest form?

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* 8. If your loss has been at least a year or longer than now, please indicate when your loss occurred.