Confidential Application

Birth Injury Support Application

We review every submission personally. This process is confidential and obligation-free.

Currently available in NY, NJ, and PA only. Other locations coming soon.

We strongly encourage families to submit within the first 3 years of childbirth. Waiting longer may limit availability.

Parent Information

First Name *

Last Name *

Email *

Phone

Child & Birth Information

Child's Date of Birth

State of Birth

Hospital Name

Diagnosed Conditions

Select any that apply:

Cerebral PalsyHIESeizuresBrachial Plexus InjuryErbs PalsyLack of Oxygen at BirthBrain CoolingBrain DamageDevelopmental DelayUndiagnosedOther

Emergency C-Section?

NICU Admission?

Your Story

What supplies are you most interested in?

I would like to be connected with an independent advocate or case review team.I confirm this information is accurate. *

Confidential

Manual Review

No Obligation

Nationwide

Birth Injury Shop

Support tools and resources for families facing birth injuries. Confidential, nationwide.

Quick Links

Home Shop Apply for Support Landing

Legal

This website provides educational information and support resources. Participation in the Birth Injury Support Program does not create a professional-client relationship. We do not provide legal advice. Any connection to independent professionals is optional and provided at your request. Support eligibility is determined at our discretion. Submission does not obligate you to pursue any claim.

All information is voluntarily submitted. Data is encrypted and transmitted securely via SSL.