Please note that participation in our program is limited to one time per mom.
Mother's Name
*
First Name
Last Name
Mother's Age
(Optional)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
*
Street Address, City, State, Zip
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Father/Partner's Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Loss
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have other children?
*
Please Select
No
Yes
If you have other children, please list them & their ages below.
Emergency Contact #1
*
First Name
Last Name
Emergency Contact #1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
*
First Name
Last Name
Emergency Contact #2 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital Delivered
*
Hospital child was treated at, if applicable.
Your Story
*
Please use the space above to share your story.
Your Support System
Please list family members, friends, organizations, churches, etc. that are currently helping you in the space above.
Are you currently in counseling, or have you had Counseling previously?
*
Yes
No
If you answered "yes" to the previous question, please explain.
How did you hear about The Finley Project®?
*
Form Completed By:
*
First Name
Last Name
I confirm I do not require support for any of the following: Co-occurring drug and alcohol related issues; Eating disorders; Persistent mania; Cognitive challenges; Non-compliance with prescribed medications; Actively suicidal; History of violence or exhibits violent tendencies; I also understand The Finley Project would not be an appropriate program for an individual who requires 24-hour visual monitoring or inpatient care.
*
I Agree
I agree to the following: 1) I am a mom who birthed a child. 2) The age of my child was over 20 weeks gestation and up to 2 years of age and then died. 3) The loss of my child happened within the last 90 days. 4) I have a willingness to go through the entire The Finley Project® program. 5) I have a willingness to complete an initial survey and a survey at 6 months. 6) I am at least 18 years of age.
*
I Agree
SUBMIT
Should be Empty: