ATTENTION
If you are completing this on behalf of a family, PLEASE note the first two categories include your information, and the rest of the application, including all contact details, pertain to the family interested in receiving services. if you have any questions, please reach out to Mary@mitchellshouse.com. Thank you!
Name of person completing the application
*
First Name
Last Name
Relationship to the Sick Child (Parent, SW at __ , other)
*
Name of Primary Guardian/ Family Contact
*
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.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / 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?
*
Does your child's diagnosis require regular infusions and/ or multiple specialty medical visits?
*
If your child has already completed treatment for their diagnosis, was their treatment completed within the past 2 years?
*
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?
*
Please verify that you are human
*
Submit
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