Application for Peer Support

Please complete this form to apply to be assigned a supporter through our Volunteer Supporter Program. Once we have your information you will be matched with an HG survivor who will be your HG Buddy for as long as you need them. They will offer support and information that we hope will help you get through this terrible time. If you ever need to get in touch please send an email to hello@hyperemesisaustralia.org.au

Name *

First Name

Last Name

Email *

Age *

Mobile *

(###)

###

####

State *

QLD

NSW

ACT

VIC

TAS

Please provide the name, number and relationship to you for an emergency contact person *

How many weeks pregnant are you? *

What is your due date? *

YYYY

Have you experienced HG in previous pregnancies? *

Yes

This is my first pregnancy

What symptoms are you experiencing? *

What treatment are you receiving? *

Do you have any other pregnancy complications? Ie Multiples, Ptyalism, Hypertension, Gestational Diabetes. We may be able to partner you with a supporter who has similar experience *

What kind of support would you like to receive from your assigned volunteer supporter? *

Thank you for completing this application! Someone from Hyperemesis Australia will be in touch with you shortly.

Email Address

Thank you!

Hyperemesis Australia acknowledges the Traditional Owners of Country throughout Australia. We recognise that First Nations’ sovereignty was never ceded and their connection to land, waters and culture is continuing. We pay our respects to their Elders past, present and emerging. This always was, and always will be Aboriginal Land.