Mitchell's House Counseling Application

Name of person completing the application*

First NameLast Name

Relationship to the Sick Child (Parent, SW at __ , other)*

Name of person(s) the counseling appointment is requested for?*

Best email for communication*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is the diagnosis?*

How old is the child who received the diagnosis?*

Are there other children who are not sick in the home? If so, what are their ages?*

How long has your child been in treatment for the illness?*

At which hospital are you receiving treatment?*

Does your child's diagnosis require multiple hospitalizations?*

Does your child's diagnosis require major surgery?*

If you child has already completed treatment for their diagnosis, was their treatment completed within the past 2 years?*

Does your child's diagnosis require regular infusions and/ or multiple specialty medical visits?*

How did you learn about counseling services at Mitchell's House?*

Who is your social worker and/or child life specialist?

Do you speak English? If not, what is your primary language?*

How old are the caregivers for the sick child?*