Helpline Follow-up Consent Form
Helpline Follow-up Consent Form
Name
*
First Name
Last Name
Preferred follow-up contact method
*
Phone call
Text message
Email
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Preferred day or time for follow-up
May we leave a voicemail?
*
Yes
No
May we send you a text message?
*
Yes
No
Preferred language
*
Please Select
English
Spanish
French
Other
Briefly describe what you would like help with. Do not include sensitive personal details.
I authorize the helpline to contact me using my selected method for follow-up about my helpline contact.
*
I agree
Submit
Should be Empty: