Patient Advocacy Intake Form
Share what’s happening and what support you need so we can help you navigate next steps.
About You
Full name
*
First Name
Middle Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you 18 years of age or older?
*
Yes
No
City/town
*
Province
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Preferred method of contact
*
Please Select
Phone
Email
Text message
Who Are You Seeking Support For?
Who are you seeking support for?
*
Myself
My child
My partner/spouse
A family member
A friend
Other
If someone else, what is your relationship to that person?
Does this person know you are contacting us?
*
Yes
No
Not applicable
Unsure
What Is Happening?
Briefly describe what is currently happening and what brought you to The Conan Fund
*
What are you hoping support can help with?
*
Finding mental health services
Navigating a hospital/ER
Inpatient mental health care
Outpatient mental health care
Finding a psychiatrist
Finding a therapist/counsellour
Finding a social worker
Rehabilitation or community programs
Communicating with a hospital or healthcare team
Contacting Patient Relations
Understanding available options
Advocating for myself or my loved one
Supporting a family member
Discharge planning
Finding community resources
Other
Current Care
Is the individual currently receiving mental health care?
*
Yes, inpatient
Yes, outpatient
Yes, through both inpatient and outpatient services
No
Unsure
If yes, where are they currently receiving care?
Have they previously sought mental health care for this concern?
*
Yes
No
What services or supports have they already tried?
What has been helpful, and what has not been helpful or met their needs?
Current Concerns
What are your biggest concerns right now?
*
Pain or symptoms
Care coordination
Understanding the diagnosis or situation
Medication issues
Discharge planning
Referral delays
Insurance or coverage issues
Communication with care team
Emotional distress
Other
What do you feel you or your loved one needs right now?
*
Is there a specific decision, appointment, discharge, referral, or situation you would like help navigating?
Upcoming appointments, assessments, discharges, or other important dates
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Immediate Safety
Is there immediate danger or risk of harm right now?
*
Yes
No
Unsure
If yes or unsure, briefly explain what is happening right now
Advocacy & Communication
Who would you like help communicating with?
Primary care provider
Specialist
Nurse
Hospital
Clinic
Insurance company
Patient Relations department
Patient advocate
Social worker
Care team
Other
Have you already contacted any of the following about this concern?
*
Hospital Patient Relations department
Patient advocate
Social worker
Care team
No
Unsure
If yes, what was the outcome?
What would you like an advocate to help you communicate or advocate for?
*
Your Goals
What would a successful outcome look like?
If we could help with one thing right now, what should it be?
Additional Information
Is there anything else the Patient Advocacy team should know about your situation?
Is there anything that would help us better understand or support you?
What do you need from us that you feel you have not been able to get from the mental health system?
Consent & Privacy
Do you consent to The Conan Fund contacting you about your intake and advocacy request?
*
Yes
No
If you are requesting support for another person, do you have that person's consent to share personal information?
*
Yes
No
Not applicable
I am unsure
Preferred communication hours
Morning
Afternoon
Evening
Submit
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