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Bereavement Support  Request

Bereavement Support Request Form

Every loss experience is unique, which is why we have designed this form to be as open-ended as possible.  By filling out the form below you will be helping us understand your situation better which will allow us to offer you the best support possible.  


We can offer support for the loss of a child at any stage including 1st trimester loss, sometimes called a miscarriage, 2nd and 3rd trimester loss, sometimes called a stillbirth or perinatal loss, these terms also encompass the loss of a child after delivery into early infancy.  We are here and will do our best to be there with you through this process in a way that is most meaningful to you.  


Currently we can assist with:

  • Providing you with a certified mental health professional to work with

  • Items to help you spend as much time as possible with your baby at Lower Keys Medical Center 

  • Items to help memorialize your time with your child

  • Additional services are being added

You will receive a confirmation email once this form is submitted.  A Coalition team member will be in contact with you within 3 business days. Thank you for your trust. We will be in touch soon.

English Speaking Only?
Creole Speaking Only?
Preferred Method of Contact

We are ready to offer you the most comprehensive bereavement support network available in the Florida Keys. Please use the space below to tell us a little bit about your story and what has happened. If there is something specific you need, please write that below as well. If you don't know what you need, that is OK too. We will have a staff member reach out and walk you through this time.

Please Note: This information is strictly confidential and any personal information will not be shared.

Thanks for submitting! We have received your request. Please be sure to check your spam folder if you do not receive a confirmation email from us.

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