HOPE FOR HEALING PREGNANCY AND INFANT LOSS SUPPORT GROUP REGISTRATION FORM

HOPE FOR HEALING PREGNANCY AND INFANT LOSS SUPPORT GROUP REGISTRATION FORM
The Journey Institute (TJI) provides free grief support groups to families on their grief journey caused by the death of a loved one. Please complete this registration form and we will be in touch to schedule an intake.
Name*

First NameLast Name
Please select which best describes you*

MotherFatherOther
Please select your race*

African American/BlackAmerican IndianAsianAlaskan NativeNative Hawaiian/Other Pacific IslanderWhiteMulti-RacialOther
Ethnicity*

HispanicNon-Hispanic
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone *
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Please select your income level*
Why does TJI need to know your household income? The mission of TJI is supported by grant funding and individual donations. Most grantors request demographic information about TJI participants, such a age, gender, race and income. This funding grants allows TJI to provide FREE grief support services. Thank you so much for assistance and participation.
When did the death of your child occur?*

During pregnancyMy child was stillbornMy infant died after birthOther
Date of Death*

MonthDayYear
Date
Will you be the only participant in the Pregnancy and Infant Loss Support Group?*
Will your significant other attend?*
I understand that additional participant information will be gathered during my intake appointment.*
Should be Empty: