Clone of Individual Support for Parents of Patients and Survivors

Support for Families of Patients and Survivors
Name of child with or recovering from cancer (if you have more than one child with cancer, please indicate the Siblings' info below)*

First NameLast Name
Child's Birthday

MonthDayYear
Date
Child's gender preference
Child's Diagnosis(es)
If your child died suddenly, please skip this question or type NA
Date of Primary Diagnosis

MonthDayYear
Date
What was their age at diagnosis?
Has your child replapsed?
Please share a little about their diagnosis and medical history below including important timelines and treatments.
All sensitive information in this form is HIPAA-compliant and password-protected.
Sibling 1

First NameLast Name
Sibling 1 Birthday

MonthDayYear
Date
Sibling 1 gender preference
Sibling 2

First NameLast Name
Sibling 2 Birthday

MonthDayYear
Date
Sibling 2 gender preference
Sibling 3

First NameLast Name
Sibling 3 Birthday

MonthDayYear
Date
Sibling 3 gender preference
Sibling 4

First NameLast Name
Sibling 4 Birthday

MonthDayYear
Date
Sibling 4 gender preference
If you have another child with cancer, a child that has died, or more children in your family not listed above, please list them with their birthday and gender preference below.
Please list an emergency contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to applicant
Heartbound Healing and Peer Support - Jeni Rhodes (Easthampton, MA)Sacred Oak Healing Services - Lori Mangano (Exeter, NH)I would like to schedule a 30-minute zoom session with both Jeni Rhodes and Lori Mangano to determine who will be the best fit for our family.

End of Life and Grief Support for Families
Name of child diagnosed with cancer or lost due to cancer (if you have more than one child with cancer, please indicate the Siblings' info below)*

First NameLast Name
Child's Birthday

MonthDayYear
Date
Child's Gender Preference
Diagnosis
Date of Diagnosis

MonthDayYear
Date
Age at Diagnosis
If your child has passed away, what is their date of death
What was their age at passing?
Please feel free to share a little about their diagnosis and medical history below (optional)
All sensitive information in this form is HIPAA-compliant and password-protected.
Sibling 1 Name

First NameLast Name
Sibling 1 Birthdate

MonthDayYear
Date
Sibling 1 Gender Preference
Sibling 2 Name

First NameLast Name
Sibling 2 Birthdate

MonthDayYear
Date
Sibling 2 Gender Preference
Sibling 3 Name

First NameLast Name
Sibling 3 Birthdate

MonthDayYear
Date
Sibling 3 Gender Preference
Sibling 4 Name

First NameLast Name
Sibling 4 Birthdate

MonthDayYear
Date
Sibling 4 Gender Preference
If you have another deceased child or more children in your family, please list them with their birthday and gender preference below
Please list an emergency contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Applicant
Bittersweet End-of-Life Doula Care - Beecher Grogan (Lebanon, ME)Sacred Oak Healing Services - Lori Mangano (Exeter, NH)I would like to schedule a 30-minute zoom session with both Beecher Grogan and Lori Mangano to determine who will be the best fit for our family.

TERMS AND CONDITIONS
To finalize your application, please read and sign below and then click Submit.
TERMS AND CONDITIONS
- Each family will be allocated $1,000 to meet virtually with either Jeni Rhodes, Beecher Grogan, or Lori Mangano, our Healing Support Guides. This will amount to approximately twelve hour-long sessions.
- After the funds are used up, families may choose to pay out of pocket directly to Jeni Rhodes, Beecher Grogan, or Lori Mangano.
- There is no restriction on geographical location.
- Jeni Rhodes, Beecher Grogan, and Lori Mangano will be working with Rett's Roost as Healing Support Guides or peer support coaches and not as licensed therapists or offering medical advice. Individual sessions with Jeni Rhodes, Beecher Grogan, and Lori Mangano should not be used in place of therapy and all participants are encouraged to obtain their own professional therapist as needed.
CONFIDENTIALITY

Rett's Roost safeguards the confidentiality of personal and medical information of participants at its programs. By participating in a Rett's Roost program, you acknowledge the confidentiality of personal and medical information that may be received from other program participants, and that you will not share the same with any outside person or entity.

CANCELLATION POLICY

If you need to cancel a session, kindly give your practitioner 24 hours notice, otherwise, Rett's Roost will need to pay for your session, and it will be deducted from your allotted funds.

LIABILITY RELEASE

On behalf of my family, I understand, accept, and assume responsibility for any and all risks, whether or not specifically itemized herein, and I acknowledge and hereby release Rett's Roost and its directors, employees, and subcontractors from all liability and any injury arising out of any reliance upon the consultation and services provided during these sessions.

I agree that I shall defend, indemnify, and hold harmless Rett’s Roost, its affiliates, its directors, employees, and subcontractrs from and against any liabilities whatsoever, including any demand, loss, costs, or expense, and reasonable attorneys’ fees and costs of investigation, resulting from my family's participation in this program. In the event of any claim is made against Rett's Roost, the matter shall be referred to the Maine Office of the American Arbitration Association for mandatory mediation, and if not successfully mediated, for mandatory arbitration. My participation in this program is subject to the terms of the Rett's Roost Privacy Policy.

I have read, understand, and agree to this waiver, including the Terms and Conditions and Cancellation Policy.
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Healing Guidance Program

Individual Support for Parents Navigating Childhood Cancer

Support for Families of Patients and Survivors

End of Life and Grief Support for Families

TERMS AND CONDITIONS