Identifying Concerns

Thank you for filling out our Family Inquiry Form. In this first part of the form, you will identify some concerns that you have for your child. The second page will ask you about the type of support you would like from AboutFace. Your answers on this form will help guide the types of programs AboutFace and Trailblazers offers in the future. All questions are mandatory unless otherwise noted. 

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* 1. Caregiver Name: 

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* 2. Child(rens)'s facial difference:

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* 3. Email:

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* 4. Province:

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* 5. Are you interested in receiving updates about programs and services through our bi-monthly newsletter? 

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* 6. Do you live in a more rural or urban setting?

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* 7. Do you belong to one or more of the following groups? (Optional)

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* 8. How did you hear about AboutFace?

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* 9. What is your primary concern for you or your child? (Only choose one option)

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* 10. What are some of your ongoing/additional concerns? (You can pick up to 3 options)

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* 11. (Optional) I am not interested in recreational programs for my child. I am only interested in seeking professional mental health support for my child (i.e., psychologists, psychiatrists, social workers) or support groups that address facial differences. Answering yes will take you to the end of the survey. To skip this question, choose "No" or scroll down and click on "NEXT".

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