NEW 25/26 Christina Sullivan Foundation Peer - Led Support Group Registration Form for Parents, Caregivers and Guardians "let's talk about it.

Christina Sullivan Foundation Peer - Led Support Group Registration Form for Parents, Caregivers and Guardians "let's talk about it.
Welcome to the Christina Sullivan Foundation monthly Virtual and In-Person meetings for parents, caregivers and guardians to share experiences, resources. and gain support from other attendees. Meeting Time: 6:30PM - 8:00PM
Next Meeting:

December 17th

Meeting In-Person Address: Shearn Moody Plaza 123 25th Street, Suite 2017, Galveston, TX 77550

Virtual attendance provide your email and a link will be sent to you.
Vision :To provide resource information, support, and advocacy for all caregiving concerns and to enhance the quality of life to all those touched by these concerns. Mision:To recognize, educate, support, and motivate family caregivers.
1.) Personal Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*

Area CodePhone Number
2.) Information about the Person You Care For.
Name*

First NameLast Name
Date Of Birth: *
Description of Challenges:*
Age:*
Intrest and Hobbies:*
Any specific needs or preferences for the support group? *
3.) Support Group Preferences:
How did you hear about this support group? (e.g., word of mouth, social media, etc.) *
What do you hope to gain from participating in this support group?*
Are there any specific topics you'd like to see discussed in the group? (e.g., advocacy, transition to adulthood, etc.)*
Is there anything we should be aware of regarding your comfort level or any sensitivities you might have? *
Please share a topic you would like to discuss and learn from other attendees.
Mental Health, Physical Health, Financial Security, Spirituality, Intellectual Well-being and Social well being
4.) Consent and Confidentiality: I understand that all information shared in the support group will be kept confidential. I agree to abide by the rules and guidelines of the support group. I give my consent for my photo and information to be used for this purpose. All information protected through HIPPA (Health Insurance Portability and Accountability Act.)
Consent and Confidentiality:

AgreedDisagree
Date*

MonthDayYear
Date
Signature*

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Christina Sullivan Foundation Peer - Led Support Group Registration Form for Parents, Caregivers and Guardians "let's talk about it.

Welcome to the Christina Sullivan Foundation monthly Virtual and In-Person meetings for parents, caregivers and guardians to share experiences, resources. and gain support from other attendees. Meeting Time: 6:30PM - 8:00PM

Vision :To provide resource information, support, and advocacy for all caregiving concerns and to enhance the quality of life to all those touched by these concerns. Mision:To recognize, educate, support, and motivate family caregivers.

1.) Personal Information

2.) Information about the Person You Care For.

3.) Support Group Preferences: