PAIL Network - Request for Support Form

To receive support services from the Pregnancy and Infant Loss Network at Sunnybrook, please fill out our intake form below.

PAIL Network provides support to any family in Ontario who has experienced the loss of their pregnancy or the death of their baby up to 12 months of age, including:

Request form

In order for us to provide you with the best possible match for peer support, please provide as much information as you are comfortable sharing. Please note, we are unable to offer support outside of the province of Ontario. The form below can not be submitted if the fields marked with an *asterisk* are incomplete.

First name

Last name

Date of birth

Address

City

Province

Postal code

Contact information

Email address

Home phone

Mobile phone

I grant my consent to be contacted via the methods listed above.

Yes

I would like to be contacted about my accessibility needs.

Yes

I request interpretation in the following language:

Support type

Please review the available peer support options below and check off any that you may be interested in. Our Referral Coordinator will review each type of support with you and help you to determine which type you would like to proceed with.

Preferred method of support is

Commemorative events Online support Support groups in my area Pregnancy after loss support Online Indigenous Peer Support

PAIL Network will contact families by phone to further discuss support needs. For other correspondence, please let us know how you would prefer to communicate with us.

Contact preference

Email Phone (home) Phone (mobile)

How did you hear about PAIL?

Please share the details of your loss

Partner's name (first, last)

Baby's name

Date of loss

Children

My story

Category of loss

First trimester loss (0-13 weeks) Second trimester loss (14-27 weeks) Third trimester loss (28-40+ weeks) Infant/neonatal death (1-12 months) Infant death due to SIDS/SUIDS (1-12 months) Termination of pregnancy Elective abortion

We understand that this loss reaches into all aspects of your life, and can also offer peer support during your pregnancy after loss, support as you are parenting through loss, and a dedicated group for the non-birthing partner in grief.

You will see a confirmation on your screen once this form has been submitted successfully. If you don't receive this confirmation, please contact us at pailnetwork@sunnybrook.ca or call 1-888-303-PAIL (7245).

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Request for support

Request form

Contact information

Support type

Please share the details of your loss

Category of loss