My Childhood Cancer Navigator Powered by SebastianStrong

Formulario en español AQUÍ.
Child's Info
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Age at Diagnosis (Must be 18 or younger at diagnosis.)*
Child's Primary Diagnosis*

Brain / Central Nervous System TumorLeukemiaLymphomaNeuroblastomaOther Solid TumorRetinoblastomaSarcoma (Bone or Soft Tissue)Unsure / Not Certain YetWilms TumorOtherOther (Please Specify)
Treating Facility*

Alex's Place/Holtz Children's Hospital (Miami)Arnold Palmer Hospital for Children (Orlando)Joe DiMaggio Children's Hospital (Hollywood)John's Hopkins All Children's Hospital (St. Petersburg)Nicklaus Children's Hospital (Miami)UF Health Shands Children's Hospital (Gainesville)Wolfson Children's Hospital (Jacksonville)Other (Please Specify)
Primary Oncologist
Parent/Guardian's Info
Primary Parent/Guardian's Name*

First NameLast Name
Relationship to Child*

MotherFatherFoster or Adoptive ParentLegal GuardianGrandparentSibling (18+)Self (18+)Other (Please Specify)
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Example: Miami-Dade
Support Needs
How can we help you?
Where are you in your child's cancer journey?*

Newly Diagnosed / In TreatmentAfter Treatment (Survivorship)After Loss (Bereavement)
What feels most urgent for your family today? (Select all that apply.)

Understanding treatment options or clinical trialsEmotional / Mental Health SupportSibling SupportSchool Accommodations / Education SupportInsurance Questions or IssuesFinancial Assistance (bills, rent, food, gas, etc)Housing or TransportationOther (Please Describe)
N - What feels most urgent for your family today? (Internal Field)
What feels most urgent for your family today? (Select all that apply.)

Understanding long-term follow up care and side effectsEmotional / Mental Health SupportSibling SupportSchool Re-Entry & Education SupportInsurance Questions or IssuesFinancial Assistance (bills, rent, food, gas, etc)Housing or TransportationResources for healthy living and wellness (nutrition, activity, coping strategies)Other (Please Describe)
S - What feels most urgent for your family today? (Internal Field)
What feels most urgent for your family today? (Select all that apply.)

I'd like to speak to another parent who has lost a childEmotional and grief support for parents/caregiversSibling grief support and programsConnecting with other bereaved familiesCounseling or support group referralsHelp with school accommodations for siblingsFinancial Assistance or Guidance (work leave, bills, etc)Memorial or remembrance resourcesOngoing check-ins and companionship after lossOther (Please Describe)
B - What feels most urgent for your family today? (Internal Field)
Preferred Language*

EnglishSpanishOther (Please Specify)
How did you hear about us?*
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Formulario en español AQUÍ.

Child's Info

Parent/Guardian's Info

Support Needs