Connections Database - Form for Mentors
Email address and/or phone number
please indicate how you would prefer to be contacted.
Please fill in your age at the time of loss
Tick the box that best describes your religious observance
Dati Leumi/Modern Orthodox
How long ago was your loss?
Within a year
1-5 years ago
5-10 years ago
Was this your first loss?
Did you have living children at the time of your loss?
Have you had living children since your loss?
Age of lost baby
Early miscarriage (up to 14 weeks)
Late miscarriage (14-24 weeks)
Stillbirth (24+ weeks)
Neonatal loss (up to approx 1 year old)
If you have you celebrated any significant milestones since your loss, please describe briefly here
eg. brit, bar/bat-mitzvah of already living or subsequent child, wedding, etc.
Is there anything in particular we should know?
eg, able to help someone decide between methods to deal with a missed miscarriage, anything you think someone might particularly need to be able to discuss
Never submit passwords through Google Forms.
Terms of Service