Funding Payment for Finished Client Assignments

- Name*
  
  First NameLast NameCredential
- Business Name*
- E-mail*
  Business email address
- CELL Number*
  
  Area CodePhone Number
- 1 hour1.5 hours2 hours2.5 hours3 hours3.5 hours4 hours4.5 hours5 hours5.5 hours6 hoursMore than 6 hours, but I am donating the additional time to my client.
- Quick Pay/Zelle with my EMAIL address given aboveQuick Pay/Zelle with my CELL NUMBER given above
- Please list all the ways you were able to help your client, especially how you impacted your client's quality of life. *
  Can you quantify your impact? i.e., money saved, back to work X days early, avoided unnecessary surgery which would have cost X, able to enter workforce again, etc.
- Client Composition *
  Choose just one that fits best
- NOTE: If you worked with a client who involved one or more Care Partners (or you were engaged by a family) please answer the demographic questions for the patient concerned.
- Gender?*
- Age? *
  if you don't know for sure, estimate.
- Ethnicity*
  Choose one
- VeteranEmotional disabilityDifferently abled physicallyDifferently abled intellectuallyHomelessCovid "long-haul" suffererPast 30-45 day hospital stayMedical error survivorSolo seniorMultiple co-morbiditiesMisdiagnosedOther
- How did you determine that your client is unable to afford professional fees? *
  Check all that apply
- How many times have you participated in the Care Partner Project Advocacy Fund? *
- Overall, how would you rate your experience with this Care Partner Project Fund? *
- Tell us what you like about the Care Partner Project Fund as well as how we could improve. We are all learning together -- all feedback most welcome!
  Optional
- With your client's permission, please provide contact information for a brief follow-up survey:
  Primary Client First Name Last Name : Email Area Code Phone Number
- Thank You!
  
  Look for your funding fulfillment within 2 business days.
- Should be Empty:

Thank You!