Perinatal Bereavement Photography Request Form

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PLEASE READ BEFORE COMPLETING FORM:
Dancing Phoenix Bereavement Photography is a non-profit project in partnership with Imani's Light, focusing on the needs of grieving families in the King/Pierce County, WA area. DUE TO AN OVERWHELMING RESPONSE FOR SUPPORT, WE CAN ONLY SERVE FAMILIES LOCATED WITHIN 30 MILES OF Seattle/Tacoma.
Please complete the form below and a Dancing Phoenix Photography representative will get back you ASAP.

Email *

Full Name *

Phone Number *

Location of Hospital/Birth Center: City & State *

Due Date *

YYYY

I identify as a BIPOC birthing person *

Yes

Please check which applies: *

I am a parent experiencing a pregnancy/infant loss

I am a parent who just received a life-limiting fetal diagnosis

I am a family member or friend supporting someone through a pregnancy/infant loss

I am a Dr./Midwife/Clinic/Community Organization referring someone who is experiencing a pregnancy/infant loss

Other:

Required

I am seeking the following support: (check all that apply)
*

I am in need of a bereavement photographer

I am in need of a Bereavement Doula

I am in need of a Perinatal Palliative Care Support

Required

Please answer the following questions so we can put you in contact with the right support:
*

I am experiencing a miscarriage in the first trimester

I am experiencing a miscarriage in the second trimester

I am experiencing a stillbirth in the second trimester

I am experiencing a stillbirth in the third trimester

My baby passed away during birth

NICU/removal of support - time TBD

My baby passed away in the NICU

Termination for medical reasons

Perinatal Palliative Care

I am in need of LGBTQ specific support

I am in need of Teen specific support

Required

If the baby has not been delivered, please provide an anticipated timeframe for delivery.

Are you currently laboring?
** Please text 206-486-2936 for the Dispatcher to connect you to a photographer ASAP** *

Yes

My preferred method of contact is:
*

Text Message

Phone Call

Via a family member, friend, or Doula that is supporting me - Please provide their contact information in Other

Other:

Would you like to be referred to our partner organization. for Grief, Bereavement, Birth Trauma Support? *

Yes

Please provide any other important details so that we can better prepare to serve your family.

Submit

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