Parent-to-Parent Request Form

Parent’s Name:

Please indicate which parent or parents would like this service:

Address: (Please include zip code)

Phone: (Please include area code)

Best time to call: (morning/afternoon/evening) at this number

Name of child who died:

Date child died:

Age child died:

Circumstances of the death: (For example: prematurely, illness, sudden unexpected, congenital condition, hospice care, decision to withhold medical treatment or withdraw life support)

Siblings (names and ages):

What are your concerns at this time?

Every effort is made to match a volunteer to you who may have similar circumstances. Please check what is the most desirable for a match. You may check more than one thing.

Age of child ______ Family issues______ Single parent_________

Circumstances of death______ Surviving siblings_______ No other living children_______

Decision to withdraw life support _____

Other (Please explain): _________________________________________________________________

____________________________________________________________________________________

the information provided on this form will be shared with the Parent-to- Parent

volunteer assigned to you.

Mail to: Pat Schaffner

Garden View 70-503

Children’s Hospitals and Clinics of Minnesota

345 N Smith Ave., St. Paul, MN 55102