Connections Database: Form for buddies
Email address or phone number
please indicate whether you would prefer to be contacted by email or by phone.
How would you best describe your religious observance?
You only need to answer this question if you would like to speak to someone whose religious observance is similar to yours
Dati Leumi/Modern Orthodox
Was this your first loss?
Age of lost baby:
Early miscarriage (up to 14 weeks)
Late miscarriage (14-24 weeks)
Stillbirth (24+ weeks)
Neo-natal loss (up to one year old)
Do you have living children?
How long ago was your loss?
within the last 6 months
within the last year
within the last 5 years
Is there any aspect of your experience which you particularly want your mentor to share/would particularly like to be able to discuss?
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