Peer Engagement Intake Form
Name
*
First Name
Last Name
Name of Parent if Client is a Minor
First Name
Last Name
DOB of Participant
-
Month
-
Day
Year
Date
* If under 18* Age of minor
Pronouns:
*
What peer support program are you applying for?
*
Adult
Minor
LGBTQAI+
CF Mom Group (Moms who have CF)
Board Game Night
Solid Ground (Faith Based)
Young Adult (college-age)
Inhale Melanin, Exhale Power
CF Fighters for Recovery and Freedom (addictions)
Ladies Night
Transplant
Youth/Teen LGBTQAI+
Caregivers
Other
Contact Information
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
CF Care Center
Can we inform your clinic that you are involved in our program? *(this will not impact your status into the program)
Yes
No
What is your timezone?
Pacific
Mountain
Central
Eastern
Preferred Mode of Initial Contact
Phone Call
Email
In one word how are you/your child feeling about Cystic Fibrosis?
My Signature confirms that I agree to the terms in the consent form, holding Attain Health and all associated parties harmless while engaging in the Peer Engagement Program. If client is under 18, guardian signature is required.
Submit
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