Intake Form A Healing Circle Intake Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Name* First Last Spouse/Partner Name*Enter NONE if not applicable.Status* Married or Significant Other Single Divorced/Separated Other If Other:Your Email* Spouse/Partner Email* Your Phone*Spouse/Partner Phone*Your Address* Street Address City State / Province / Region ZIP / Postal Code Spouse/Partner Address* Street Address City State / Province / Region ZIP / Postal Code Emergency Contact Name*Emergency Contact Phone*Emergency Contact Relationship*Nearest Hospital with Emergency Room:*Please Provide Name, Address, Phone Number (This is a legal requirement)Date of Loss* MM slash DD slash YYYY Stage of Pregnancy*Brief Description of Your Loss*Hospital(s) Involved in Your Care*Physician(s) Involved in Your Care*Any Previous Losses? If "Yes" Please Briefly DescribeAre You Currently Seeing a Mental Health Professional? Yes No Do You Have Other Children? If so, Names & Ages?Anything Else Relevant to Your Loss or Participation in the Group?*Do You Prefer an Online Group or an In-Person Group in Santa Monica?* Online In-Person Either How Did You Find Us?* Social Media Google Another Online Site Referred by Previous Group Member Word of Mouth Hospital or Social Worker Physician or Medical Personnel Other If Other, Please Let Us Know How You Found Us.NEXT STEP Thank you for completing this form. You'll be contacted to discuss placement in a group within the next 1 to 2 business days. We look forward to talking to you.
