Steady_Hearts_Intake_Form

1
Finding the Right Support Pathway

Every family's situation is different - emotionally, medically, and financially. To make sure we offer the right level of support without adding pressure, we use flexible support pathways. There are no "right" or "wrong" answers here. This helps us care for you well and sustainably

To ensure we can continue offering reduced-rate support, families selecting our lowest-cost pathways may be asked to provide a simple form of income or benefits verification. We keep this process minimal and respectful, and we review documentation privately.
2
Which statement best reflects your current situation?
We are experiencing significant financial strain and need the most affordable support possible right now.
We are on a fixed or limited income and need flexible, lower-cost support.
We have some financial stability and are able to invest in ongoing advocacy support.
We are financially stable and are seeking comprehensive, high-touch support.
3
What are you hoping support will help with most right now?(Select all that apply)
Understanding diagnosis, scans, or labs
Preparing for appointments or second opinions
Organizing medications, records, or schedules
Coordinating care between providers
Ongoing caregiver support and guidance
Navigating advanced illness or care transitions
4
How urgent does support feel right now?
Immediate (appointment or decision within 72 hours)
Immediate (appointment or decision within 72 hours)
Unsure
Ongoing support, not time-sensitive
5
What best describes your role?
Patient
Primary Caregiver
Shared Care giver (Family/Friends)
Adult Child Caring For Parent
Spouse/ Partner
Other
6
How comfortable are you with digital tools ?(apps, online forms, etc.)
Very Comfortable
Somewhat Comfortable
Prefer Minimal Digital Tools
Prefer Mostly Printed Support
7
Is there anything youd like us to know about your situation right now
8
I understand that Steady Hearts provides advocacy, care coordination, and organizational support and does not provide medical advice, diagnosis, or treatment.
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