Bereavement self referral

Request Family Connects nurse support

Finding support after you have lost a pregnancy, newborn, or partner who gave birth can be tough. A Family Connects registered nurse can visit or call when you're ready, and can offer support for the whole family. If you live in Pierce County and recently lost a pregnancy, infant, or birthing parent (with delivery 12 weeks ago or less), use this form to request a free visit or call. The nurse can make sure you are recovering well, connect you to counseling or support groups, and answer questions you may have. This form uses encryption technology so your protected health information will be kept private. For questions, email info@familyconnectswa.org.
Your family's information

Please tell us a little bit about your family, so we can contact you and schedule.
Parent or primary caregiver's name*

First NameLast Name
Parent or primary caregiver's date of birth*

MonthDayYear
Date
Delivery date*
Address (include street, city)
Zip code*
Phone number(s)*
Preferred language

EnglishSpanishOther
Your healthcare

Please give us a little information about the healthcare you are receiving so we know who to communicate with if necessary.
Prenatal care provider
Your doctor/midwife, or name of the clinic or group
Where did (or will) you give birth?*

Tacoma GeneralSt. Joseph Medical CenterMidwifery Birth Center at St JosephGood SamaritanMadigan Army Medical CenterBirthing InnHomeOther
Are you currently receiving Maternity Support Services? (Some people can receive both).

Yes, through AnswersYes, through Step By StepYes, through other (or uncertain which)UnsureNo
Insurance provider
Write "none" if uninsured
Is there anything else you'd like to share with us?
How did you hear about Family Connects?
By pressing submit, I acknowledge that this information will be shared with the implemeting agencies of Family Connects Pierce County which may include HopeSparks Family Services, Answers Counseling, and/or Step by Step Family Support.
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