#GivingTuesday 2022 Intake Questionnaire

Hi there! Thank you for your interest in my GivingTuesday program to provide free massage therapy to local cancer patients and caregivers. Please feel free to read some information about this program below and then submit your intake form for your free massage--I will reach out from there to discuss scheduling.

My name is Courtney Ulrich and I'm a local massage therapist and Manual Lymphatic Drainage therapist. I work at Indy Massage Company (in the Keystone/Castleton area) and also own a small business providing massage therapy and wellness education to my clientele.

For Giving Tuesday 2022, I raised funds for thirty 60-minute massages for local cancer patients and caregivers. I was recently a caregiver for my grandfather during his throat cancer treatment and am excited to bring this GivingTuesday program to Indy as a way to give back to my community.

If you know of any cancer patients (in treatment or recovery) or caregivers within your community who would benefit from this opportunity to relax and temporarily step away from day-to-day cares, please share this jotform with them.

https://form.jotform.com/223353874863061

If you have any questions, please feel free to contact me:

Courtney Ulrich

317-445-9098 (text or call)

hello@courtneyulrich.com

Just FYI, these appointments are first come, first served. :-) I look forward to meeting you!

Name*

First NameLast Name

Email (your scheduling link will be sent to this email)*

example@example.com

Are you a cancer patient or caregiver for someone going though cancer?*

Cancer Patient - currently in treatmentCancer Patient - currently in recoveryCaregiver for someone going through cancer

Who referred you to this #GivingTuesday program? How did you find out about this?*

If you are currently connected with a local (greater Indianapolis) cancer center, and you feel so inclined, please provide contact information for the social worker who you may have been in contact with. This is not required for your session, but it will help this program reach more patients and caregivers! :-)

Please check the box to confirm you understand. If you are a cancer patient, currently in treatment or currently in recovery, you must confirm with your physician or cancer specialist to be cleared for massage therapy or manual lymphatic drainage (MLD). As every treatment plan is unique, it is your responsibility to confirm if a massage or MLD is appropriate for your case and at what point during your treatment/recovery would be most appropriate (before chemo, post-op, radiation recovery, etc).*

Yes, I understand.No, I don't understand.I am a caregiver.

#GivingTuesday '22 Intake Questionnaire