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.
1.Your email address
2.Your first & last name
3.Your best contact number
4.Please share which type of loss you have experienced.  Check all that apply.
5.Did your loss include any of the following special circumstances?  Check all that apply.
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.
7.Did your loss occur at least one year or more from the time you are submitting this interest form?
8.If your loss has been at least a year or longer than now, please indicate when your loss occurred.