Discovery Call Request
Share a Bit More of Your Story for a Child Life Private Session
Step 1. Intake Form
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred method of communication:
Email
Text
Phone Call
How did you hear about Child Life To Go?
*
List everyone in your household (First Name, Relationship, Age):
To help us assess eligibility for financial assistance, please provide the following information about your household income (supporting documentation may be requested upon billing). This information will be kept confidential and used solely for the purpose of determining scholarship eligibility.
*
Less than $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000+
Additional Information: If there are any special circumstances or additional information you would like to share regarding your financial situation, please use the space below:
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Context for Private Session
Who would the child life private session be for? (Name, Relationship, Age if a Child/Teen)
Reason for requesting private sessions?
Managing a new diagnosis of self or loved one
Preparation for a medical situation (procedure, treatment, change of treatment such as palliative care or hospice)
Grief or bereavement care (funeral support, life after loss, etc.)
Therapeutic or medical play to process a medical situation
Parenting support
Sibling support
Other
Please briefly explain more of the situation surrounding the child life consultation.
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Goals and Next Steps
What are 1-2 potential goals you have in meeting with a Child Life Specialist?
Anything else you would like us to know? (Interests of the child, etc.)
Complete Step 1
Should be Empty: