KY F2F HIC Support Request Form

KY F2F HIC Support Request Form

Kentucky Family to Family Health Information Center provides peer support to assist families/caregivers/parents of children with special health care needs in navigating complex health care systems. We do not collect or manage Patient Health Information (PHI) or medical forms/documentation. Disclaimer: Kentucky Family to Family Health Information Center is not a legal services agency and cannot provide legal advice or legal representation. Any information contained in this message is not intended as legal advice and should not be used as a substitution for legal advice.
KY F2F HIC provides services to families/parents/caregivers of children and youth with special health care needs. Please identify if you are a parent/caregiver of children/youth with special health care needs.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Type

Other
Zip Code
County
What type of support are you interested in as a parent/caregiver of a child/youth with special health care needs?

Other
What is your preferred spoken language?
Please list any accommodations or additional information for our team.
How did you hear about KY F2F HIC?
Select One
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