Discovery Call Request Form
Share a Bit More of Your Story for a Child Life Private Session
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. 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 the Consultation
Who would the child life private session be for? (Name, Relationship, Age if a Child/Teen)
Reason for making a child life consultation today?
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
Please briefly explain more of the situation surrounding the child life consultation.
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Goals and Next Steps
What are your goals for our time together?
Anything else you would like me to know? (Interests of the child, etc.)
When are you available for a free, 15 minute conversation to explore moving forward with a child life private session?
Not available during the proposed times?
If you are unavailable for any of the proposed times, please email Allie at Allie@ChildLifeToGo.co and we can find a better arrangement for your schedule.
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