Heartstrings, Inc.

Connections Referred Parent Form

Registration form heading

* First Name

* Last Name

* Email

* Relationship to baby lost

* Address

* City

* State

* Postal Code

* Please enter the county you reside in

* Phone

* Mobile Phone

* May we leave a message on your answering machine or voice mail?

* Would you prefer we contact you at...

* Birthday

* Marital Status

* Race/Ethnicity (for purposes of grant and donor funding)

Employer

* Average Yearly Income (for purposes of grant and donor funding)

Religious Denomination (if any)

Language(s) spoken other than English (if any)

How did you learn about Heartstrings?

* Referral Type

* Referring Organization

* Referral Source

Referral Name

* Was this the first time you learned about Heartstrings?

* How did you learn about Heartstrings?

* When did you learn about Heartstrings?

Please enter the following information regarding your partner:

Partner's First Name

Partner's Last Name

Partner's Relationship to baby lost

Partner's Street Address (if different from above)

Partner's City

Partner's State

Partner's ZIP

Partner's Home Phone

Partner's Cell Phone

Partner's Email

Partner's Race/Ethnicity (for purposes of grant and donor funding)

Partner's Employer

Partner's Religious Denomination (if any)

Partner's Language(s) spoken other than English (if any)

Please complete the following questions about the loss of your baby:

* What date did the death of your baby or child occur?

* Loss Type

* What was the age or gestational age of your child at death?

* Did your baby spend any time in the neonatal intensive care unit?

* Where did the death of your baby occur?

How old was the baby?

* What was the cause of death?

What is/was the due date of your baby?

What is your child's name? (First, Middle, Last)

Names of living children/date of birth/sex (if applicable)

* I give my (our) permission to release my (our) names, telephone number, and other relevant information to another parent for a Connections match.

State of North Carolina Release and Waiver of Claims I do hereby desire to participate in the Support Programs, including either or both Support Group and/or Connections one-to-one support, offered by Heartstrings, Inc. ("Heartstrings") and any and all activities offered by Heartstrings in connection with the same. In consideration of my participation in the Support Programs, I, on behalf of myself, my heirs, assignees, and personal representatives, voluntarily and with knowledge, hereby assume any and all risk of accident or damages, physical or mental, to my person or my property which may be incurred from or be connected in any manner with my participation in the Support Programs. I further hereby release and forever discharge Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates, and other participants from any and all liability, claims, demands, actions, causes of action, loss, injuries, costs, or expenses, including attorney's fees, that may arise from my participation in the Support Programs. I further waive and promise not to sue upon any claims, arising pursuant to statute or under common law against the Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates, and other participants, arising directly or indirectly from or attributable in any way to any negligence, action, omission, or failure to act by any such person or organization with regard to any and all activities associated with the Support Programs. I hereby assume full responsibility for and risk of bodily or emotional injury, death or property damage due to the acts, failure to act, negligence, conduct or intentional torts of Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants, while on the premises of the same or while observing, working for or in any way participating in the above-described any and all activities associated with or offered in connection with the Support Programs. I expressly acknowledge and agree that the activities of the above-described event may involve the risk of serious physical, emotional and/or psychological injury to myself and/or damage to my property. I further agree that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the laws of the State of North Carolina and that if any portion of it is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have read and voluntarily sign this Release and Waiver of Liability and further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made.

I acknowledge and agree to the terms set forth above

Heartstrings Feelings Inventory

Since the loss of my baby(ies), I feel:

* Sad:

* Scared:

* Exhausted:

* Angry:

* Lonely:

* Confused:

* Guilty:

* Nervous:

* Shock:

* Denial:

* Hopeless:

Since my loss, I have experiencced the following:

* Changes in my appetite (eating more):

* Changes in my appetite (eating less):

* Changes in my sleep (I am sleeping more):

* Changes in my sleep (I am sleeping less):

* Constant thoughts of my baby or the loss of my baby:

Changes in normal activities, responsibilities and relationships, specifically:

* Work (difficulty doing work for which I am paid):

* Work (changes in my attendance at work, increased lateness and/or absences from work):

* Following My Loss, I (Check All That Apply):

* Household (difficulty completing household tasks like I used to; cleaning, laundry, making bed)

* Self-care (difficulty getting out of bed, bathing/showering, getting dressed, preparing meals):

* My relationship with my partner/spouse is deteriorated or strained:

* Difficulty caring for others whose care I am responsible for (partner, living children, relatives, pets):

* My involvement in any living child's or children's school (help with homework, attending school conferences):

* Difficulty talking with extended family and friends, especially about my feeling about my loss:

* Following My Loss, My Religious Beliefs Or Faith Have Been (Check All That Apply):

* Less self-confidence:

* My Current Support System Includes (Check All That Apply)

* Thoughts about harming myself or someone else:

(If you selected "most of the time" or “all the time" for this question, please contact your medical doctor, mental health provider, or 911 for immediate support.)

About the Connections Program

We are sorry for the loss of your baby(ies). As you struggle through the days and nights that follow, you may feel as though you are the only person in the world who has the feelings you have and you are right. Even our closest family members and friends who have stood by us through our loss have a different experience than we do. Yet there is no time in our lives that we need others more. Through Heartstrings Connections, you can talk with someone who has felt the pain of losing a baby, struggled with the same questions, and reluctantly given up the lives they too had counted on yet had the courage to move on in this world. You don't have to be alone during this difficult time. Please complete the Participant Information Form if you are interested in a match with a support parent. We will match you with someone who has experienced a similar loss more than one year ago for one-to-one support and encouragement in person, by phone or by email - whichever you prefer. We have both men and women who have the desire to encourage you during this difficult time. Give us a call today.