Support Group Intake Form
I identify my gender as:
What peer support program are you applying for?
Are you applying individually or as a part of a clinic group
With clinic. Please notate which clinic in "other" box
ONLY FILL THIS OUT IF YOU ARE A CAREGIVER APPLYING FOR YOUR CHILD: the only information we will collect about your child is their name and age. This is used only for the purpose of locating the best group. We will not use their information for any other purpose other than clinic contact, if desired.
Name of Parent if Client is a Minor
* If under 18* Age of minor
State where you reside
What is your timezone?
Preferred Mode of Initial Contact
CF Care Center (of you, your child or your significant other)
Clinic Social Worker
Name and Number
Can we inform your clinic that you are involved in our program? *(this will not impact your approval into the program)
In one word how are you/your child feeling about Cystic Fibrosis?
In a couple of sentences-what are you hoping to gain from engaging in our program?
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 Exhale Program. If client is under 18, guardian signature is required.
Should be Empty: