Mothers’ Milk Bank of North Texas:

Bereaved Parent Support Group - Registration Form
 

At Mothers’ Milk Bank of North Texas, we recognize the profound grief that follows pregnancy and infant loss. To support families navigating this difficult journey, we have established this bereaved parent support group, where parents can join a safe, compassionate platform from near and far to share experiences, find comfort and honor the memory of their babies.

Led by a trained facilitator, Briana Sampson, LMFT and certified Perinatal Mental Health Counselor (PMH-C), the group offers peer support and guided discussions to help parents process their loss and connect with others who understand the unique pain of losing a child. Whether your loss was recent or years ago, you are welcome.

Thank you for your interest in participating - please carefully read the following information and complete the form to register. You will receive the secure virtual link to join from securevideo.com ahead of the scheduled session:   

Participant Information

If you would like to share about your loss experience in advance of the session, please do so here: (this is not required for participation)
Will anyone else be joining you for the session?
lease list their name(s)/relationship to you. If joining separately, include an email address for their unique virtual link to join:
 

Support Contact 

Please provide the name and phone number of a trusted support person (such as a friend, partner, or family member) whom we may contact if you need additional support during or after the group.
 

Acknowledgement & Consent

 
Purpose of the Bereaved Parent Support Group
This Bereaved Parent Support Group (the Group) is facilitated by a Licensed Marriage and Family Therapist (LMFT). While the facilitator is a licensed professional, please note that the facilitator will not provide therapeutic services, psychotherapy, or mental health treatment on an individualized or group basis. The Group’s focus is on peer support, shared experiences, and coping strategies within a supportive community setting where participants work with each other for their mutual benefit. The facilitator’s role is only to foster constructive conversations amongst the participants.

Confidentiality
To foster a safe and respectful environment, participants, as well as the facilitator, are to maintain the confidentiality of all personal data, opinions, or other information shared during Group sessions. However, please be aware that confidentiality may not apply in cases where there is a legal obligation to report concerns, such as where there are threats of harm to oneself or others.

Acknowledgment and Consent
By signing this form, you acknowledge and agree to the following:
  1. You understand that the Group is not professional therapy or medical treatment and is not intended to substitute for such therapy or treatment.
  2. You agree to participate voluntarily and understand that the facilitator’s role is to guide Group discussions to allow participants to address and support each other rather than provide individual or group therapy.
  3. You release the facilitator, the hosting organization, and its affiliates, employees, and agents from any liability related to your participation in the support group.
  4. You understand that the Group is not intended or suitable for crisis intervention or other acute or emergency needs. You further agree that should you need crisis intervention or acute or emergency needs, you will call 911 or otherwise seek immediate professional help.