Heaven’s Gain Ministries New Client Form

For immediate help, still fill out this form for client information, but also call our 16 hour a day hotline at 513-888-4200 between the hours of 8:00 a.m. and 12:00 a.m. Eastern Time every day! We are fastest at answering the hotline.

Please read this Hold Harmless Form

CLIENT DETAILS

Date *

What type of Pregnancy Loss Services are you requesting? *

I have not delivered my baby and need a birth plan
I delivered my baby and would like Peer Support Services

Client Name *

First

Last

Phone *

What time zone are you in? *

Eastern Time Zone
Central Time Zone
Mountain Time Zone
Pacific Time Zone

What is the best time to reach you? Any times we shouldn't call? *

Email *

Mailing Address *

Address Line 1

City

State

Zip Code

Spouse/Partner/Emergency Contact Name *

First

Last

Spouse/Partner/Emergency Contact Phone

Spouse/Partner/Emergency Contact Email

HEALTHCARE DETAILS

Weeks Pregnant *

What was your original due date *

According to the ultrasound, at what age did your baby die? *

Number of previous losses *

Gestational age of previous losses *

Current Healthcare Provider *

Provider Phone

Provider's Preferred Hospital *

Number of living children *

Medical History of this pregnancy *

Any other information or issues you would like to disclose

Do you have any fertility issues? *

I understand that in order to request free services, I have read and agree to the APPL Hold Harmless Form (located at the top of this webpage) *

Signature (please type your name as your signature) *

Call Us: +1 (513) 607-6083
heavensgain.staff@gmail.com

Call Us: +1 (513) 888-4200

In observance of Good Friday, we will close at 11:00 a.m. Eastern Time on Friday, April 18, 2025.

Heaven’s Gain Ministries New Client Form

CLIENT DETAILS

HEALTHCARE DETAILS