Support Request

Support Request

Awakening Grace strives to support and serve families enduring the loss of a child during any stage of pregnancy and during infancy, up to 12 months of age. We also serve families that have already gone through this loss, but may still be struggling. This form will be used to collect that family's information so that we may send them a care package appropriate for their specific loss.
Your Name (name of the person entering this information)*

First NameLast Name
Preferred contact method*

CallTextEmail
Your Email:*
Your phone number:*
Was consent given from the family to receive services? (If not, clicking yes gives us your consent to send to the family.)*

YesNo
Do you (the person filling out this form) want to be added to our newsletter list? This is a once a month update. *

YesNo
How did you hear about Awakening Grace?
Today’s Date*

MonthDayYear
Date
Mother's Name (If known)

First NameLast Name
Father's Name (If known)

First NameLast Name
Is there a name or nickname that the family has chosen for their baby?
Are there other children in the home? If so, what are the genders and their approximate ages?
What name(s) should the package be addressed to?*
What is the complete shipping address for the family? *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the primary language of the family?*

EnglishSpanishOther
How many babies?*

One babyTwinsTriplets
How many weeks gestation or weeks/months old was the baby when they passed away? *
PLEASE specify if it's weeks pregnant(gestation) or days/weeks old.
What month did the baby pass away? *
(We use this information to customize a birthstone in the care package. If you would rather us honor the due date month/ or the birth month of the baby, include that as well)
When did the loss occur?*

Ectopic lossMiscarriage (up to 20 Weeks)Stillbirth (20 weeks gestation and up)Infant Loss (Loss after the birth of child)
What is the gender of the baby?*

GirlBoyUnknown
Would you (the family) prefer a white memory bear/blanket or a colored bear/blanket? What is your color preference?
We will do our best to accommodate your request, but if color is not available we will send white. If unknown, leave blank and we will send a neutral color.
Do you (or the family) associate a specific animal with your child who died? What is your animal preference?
If there is no specific animal you associate with your baby, please leave blank.
Some of our items and resources include Christian beliefs. If the family of loss would like to be exempt from those items, please check the exempt box. If the religion of the family is unknown, please check the unknown box and we will refrain from using those items and resources.*

ExemptUnknownMay include Christian-based resources
Are any other services needed? (Check all that apply)

Miscarriage Retrieval Kit to assist with the physical part of loss (needed BEFORE birth occurs for gestations under 20 weeks. This is for local delivery only due to being time sensitive. This is different than the care package this form is requesting)Physical or emotional support before or during a loss. This can be at home, in the hospital, or virtual (bereavement support doula)Peer SupportMonthly Zoom Virtual Support GroupFacebook Facebook Peer Support PageDay Retreat (Every spring in central Iowa)PhotographyBurial GarmentEctopic loss support (special books for this)IVF/infertility loss support (special book for this)NoneBooks and Resources for FathersBooks and Resources for TeensBooks and Resources for GrandparentsOther
If a burial/memorial garment is desired, what size?

Sleep Sack (4-12 weeks)Sleep Wrap (12-20 weeks)Gown/Suit (20+ weeks, including infant)
If you are filling this form out for yourself, would you like us to honor your baby's special date in our monthly newsletter? If so, please tell us what name and what date you'd like us to honor.
Example: Baby Johnson born on 5-19-2024. Allie Sue Smith miscarriaged and birthed on 8-18-2023 but wanting to celebrate her on her due date day on 2-10-2024
Have you had any pregnancy or infancy losses in the past? If you would like us to recognize them in your care package as well, please include the month of that loss for each additional loss that you have had.
We would add a birthstone for each loss. Ex: mother had a loss in April 2011, December 2014 and May 2024.
Additional Questions or Comments:
If you feel comfortable, please share why baby passed away, anything that reminds you of baby, if anything made them special to you, etc.
If you are referring a friend, would you like us to include a personal note?
Make sure to include your name in the note if you want us to write it on the note.

Please consider donating towards Awakening Grace services. Thank you for your support!

USDThis is completely optional and not required for the family to receive a care package or other services from Awakening Grace.

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