Post Delivery Intake Form

Parent Information

Name

This address will receive a confirmation email

Phone

Mailing Address (If you live outside of Colorado we do not currently have the resources to offer you our services. We are so sorry.)

Are you married?

Yes No

Partner's Name

Partner's Email

Partner's Phone

Partner's Address

Baby Information

Baby's Full Name

Baby's Gender

Boy Girl

Baby's Due Date

Baby's Birthday

Date of Passing

Hospital and City of Birth

Did you receive a WWM Keepsake Crate in the hospital

Yes No

Number of Weeks Pregnant (If Applicable/ If your loss was before 22 weeks gestation we do not currently have the resources to offer you our services. We are so sorry)

Gestation / Age (If your loss was before 22 weeks gestation we do not currently have the resources to offer you our services. We are so sorry.

2nd Trimester 3rd Trimester Full Term (38 weeks and beyond) 1-3 Months 3-6 Months

Baby's Weight

Please enter a value for each in lbs and oz
(5lbs 3oz, 0lbs 8oz)

Lbs

Cause of Passing / Diagnosis (If Known)

For multiples (i.e. twins, triplets) please use this space to answer the above questions for each child.

Please Briefly Tell Us Your Story

Additional Information

How were you referred to us? (Name of Individual or Place)

Number of Living Children

None 1 2 3 4 5+

Name(s) / Age(s) (If Applicable/If you would like gifts/resources to be sent for your child/children their age must be given)

Funeral Assistance and Additional Support Resources

Please contact me as soon as possible regarding accessing a Funeral Assistance Fund

Yes No

Friend/Family Member/Other Support person we can send additional resources to:

Contact Name

Contact's Phone #

Contact's Email

If applicable, please share your religious affiliation and home church, so that we can better care for you.

Parental Consent, Authorization, and Release Agreement

(the “Agreement”)

Walk With Me (“Walk With Me”) is a Colorado nonprofit organization whose mission is to provide refuge for grieving families and help them break through barriers that stand in the way of hope.

Walk With Me provides its services to its Clients free of charge. As a Client and in consideration for the services provided by Walk With Me, I consent to, agree to, understand, and represent the following:

1. Parent or Legal Guardian Representation. I represent that I am the parent or legal guardian of the Child or Children set forth below, and I have the authority to enter into this Agreement as the parent or legal guardian of the Child or Children.

2. Non-Affiliation. Walk With Me is not affiliated, associated, authorized, endorsed by, or in any way official connected with any hospital, doctor, medical provider, clinic, psychologist (or any mental health practitioner of any kind), health insurance company, or any government program.

3. Confidentiality. I understand that the information contained in this Agreement and any information disclosed or provided to Walk With Me as a result of this Agreement shall at all times remain confidential and will not be released to any unaffiliated third party without my prior written consent.

4. Authorized Disclosure. The information contained in this Agreement and any information disclosed or provided to Walk With Me as a result of this Agreement may be shared amongst the officers, agents, employees, and volunteers of Walk With Me without my prior written consent.

5. Hold Harmless. In consideration for the services provided to me by Walk With Me, I waive and release any and all claims against: Walk With Me; the owners of premises on which Walk With Me's services are provided (collectively, “Landowners”); and Walk With Me's and Landowners’ directors, officers, agents, employees, volunteers and affiliates (collectively, the “Released Parties”), for any and all claims, loss, or damage (including attorney’s fees) resulting from: injury to a person including death; injury to property; mental or emotional distress; psychological injury; or pain and suffering caused by or arising directly or indirectly from the services provided to me or my Child or Children by Walk With Me, regardless of the cause and even if caused by negligence, whether passive or active. I agree not to sue any of the Released Parties on the basis of these waived and released claims. Landowners include, but are not limited to hospitals and clinics where any Walk With Me services are provided to Client, Client’s Child, or Client’s Children.

6. Indemnification. I will defend, indemnify and hold the Released Parties harmless from and against any and all liability, loss, damages, claims and attorney’s fees that may be suffered by any Released Party resulting directly or indirectly from the services provided by Walk With Me to Client, Client’s Child, or Client’s Children.

7. Acknowledgments. The consent, authorizations, or releases contained in this Agreement may be revoked at any time by my written statement to Walk With Me. I understand that I am freely, voluntarily, and without coercion entering into this Agreement with Walk With Me.

Signature

Date

*By entering my name in the box above I am agreeing that I have reviewed Walk With Me's Parental Consent, Authorization, and Release Agreement and agree to their tems and conditions

Post Delivery Intake Form

Description

Please Fix the Following