Heartstrings, Inc.

Pregnancy and Infant Loss Support Interest Form

Please enter the following information regarding yourself:

* First Name

* Last Name

* Email

* Address

* City

* State

* ZIP

* Phone

* Mobile Phone

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

* Would you prefer we contact you at...

* Relationship to baby lost

* Birthdate

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

How did you learn about Heartstrings?

* Which Heartstrings program are you interested in?

* Referral Type

Referral Name

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

* What is/was the due date of your baby?

* When is your baby's birthdate?

* What date did the death of your baby occur?

* Loss Type

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

What was your baby's name (if applicable)?

First

Middle

Last

Release of Information

I Give My Permission To Release My(Our) Names And Other Relevant Information To Heartstrings’ Staff, Group Facilitator, And/or Connections Support Parent In Order To Arrange The Services I Have Requested:

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.

* Please enter the county you reside in

I acknowledge and agree to the terms set forth above.

About The Support Groups

Heartstrings provides valuable peer-based support groups for anyone who has experienced the loss of a baby(ies), from conception to one year of age. Our Pregnancy and Infant Loss Support Groups provide parents the opportunity to meet other bereaved parents, receive specific grief education and tell their story, as they honor the memory of their baby(ies).

Our Pregnancy and Infant Loss Support Groups are held in Greensboro, Winston-Salem, High Point and Kernersville. Unique to Heartstrings, each of our support groups are facilitated by a licensed clinician and co-facilitated by a bereaved parent who has been trained in The Heartstrings Method©.

Our 8-session support groups span a 12-week period and are led by a licensed clinician and a bereaved parent, who is at least one year from his/her own loss. Both facilitators are trained in The Heartstrings Method and our specific curriculum. Groups are small, usually 12 participants, which allows for necessary connection, support and trust to form among the parents. Our peer based support group follows a curriculum that focuses on grief education, self-care, sharing stories of loss, exploring ways to remember, unique features of grief and healing for men and women, and how to navigate ongoing healing.

Our Connections Program offers one-to-one peer support to newly bereaved parents. Through Connections, newly bereaved parents are carefully matched with a Connections Support Parent who has previously experienced a similar loss. Support Parents are grieving parents who are at least one year out from their own loss, and have completed our comprehensive Connections Support Parent Training. Connections matches are set up for a 3-month period and parents can be in contact with their Connections Support Parent by phone, in-person and via email. The benefit of having another parent to talk with who understands the unique experience of pregnancy and infant loss is significant. There is no cost for any our programs.