Introduction Form for Grief & Loss Programs

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I am so glad that you are here, this is an important step in your grief journey. I would like to get to know some brief information about you to make sure that we are a match.

Once I have reviewed the Introduction Form, I will email you with a link to create a full profile on Simple Practice software. That will be where you will complete your Registration forms, schedule your sessions, pay your registration fee, view your billing and view your handouts.

On the morning of your 1-on-1 session, you will be emailed the private link to our virtual session. Find a quiet place at your appointment time and let's talk. You can be on your cell phone or laptop.

I have lots to share with you and am honored to be here with you during this difficult time.

If you have any questions, you can email me directly at kathryn@kathryngardner.com

Look forward to talking soon,

Kathryn

Kathryn Gardner, LCPC, PMH-C, CHC

Email *

Name *

Phone number *

Best email address to contact you *

What type of pregnancy complication or loss have you experienced? (select as many that apply to you) *

Difficult diagnosis about baby during pregnancy

Found out baby will not survive the pregnancy

Unknowns about your baby's health in pregnancy

Chemical pregnancy

Ectopic pregnancy

No heartbeat for baby

Miscarriage (pregnancy loss between 1 week and 20 weeks gestation)

Stillbirth (pregnancy loss between 20 weeks and 40 weeks gestation)

Baby was deceased at delivery

Baby survived delivery, however died as a newborn

Infant death

Other:

Required

What was the date of your pregnancy complications, miscarriage, stillbirth or infant death? *

Have you had multiple losses or difficult pregnancies? *

Have you seen a professional to cope with your grief? *

Grief counselor

Therapist

Psychiatrist

Talked with your OB team

Talked to your midwife

Met with your minister or priest

Attended a support group

Other:

Required

I am interested in the grief program. *

I would like to participate in the 3 week program

I would like to participate in the 6 week program

I am unsure if I would like to do the 3 week versus the 6 week program

I have questions before I sign up, please contact me.

Other:

Required

Thank you!

Thank you for taking the time to complete this Introduction Form. I will review it and be in touch via email soon.

Kathryn Gardner

kathryn@kathryngardner.com

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