Thank you for your interest in participating in our loss support program.

This intake form helps us better understand your background and support needs so we can match you with the appropriate group and facilitator. Please note your responses will remain confidential and are only used to ensure a safe and supportive group experience.
Name
Our intake coordinator will reach out by text to you within 48 hours
Address
Which loss support pathway(s) are you most interested in? You can find descriptions of each pathway on our Loss Support page of our website.
Select all that apply. A facilitator will personally follow up with you to clarify your needs and help place you in the most supportive group available. Your selections help guide the conversation.
Are you currently experiencing or anticipating a miscarriage or stillbirth?
What is your connection to pregnancy loss?
(Select the option that best applies to you)
Use the scale above, where 1 reflects very low well-being and 10 reflects very strong well-being.

Support and Needs

Please share what brought you to this group.  Pregnancy loss can deeply affect not only the person who physically experienced it, but also partners, family members, and others who shared in that experience. The following questions apply to everyone who has been impacted by a loss, in whatever way feels true for you.
What type of pregnancy loss have you experienced?
(optional)
(optional)

Participant Safety Information

Your safety and wellbeing matter to us. We ask for emergency contact and relevant medical information so our facilitators are prepared in the unlikely event of an emergency during group sessions. Completing this section now is optional, but this information will be required before participating in a group.
Please share any ongoing medical conditions, allergies, or health considerations we should be aware of to support your safety.
Please share any medications, treatments, or specific actions that may be needed in an emergency (e.g., EpiPen use, seizure response, insulin needs).

Help Us Extend Our Support to Others

These questions help us better understand who we’re reaching and supports our grant applications, so we can continue improving access to care and support for everyone in our community. Answer only what you’re comfortable with.
How did you hear about Missing Pieces Support Group?
Gender
We know gender identity is diverse and these labels may not reflect everyone’s experience. Our database currently only supports the options above, though we recognize they are not fully inclusive.
Race/Ethnicity
Our programs are free thanks to grant funding from foundations that require us to share demographic information. By answering, you help us show the reach and impact of MPSG, which makes it possible to continue offering support at no cost. We’re grateful for your help.
To help us better understand who we’re reaching, feel free to share any other communities or experiences you identify with that are meaningful to you (e.g., cultural background, LGBTQ+, faith, veteran, health conditions, etc.)