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* 1. Patient Services

Please choose the number that best represents how helpful the following ACCOIN services were:

  1 (Not Helpful) 2 3 4 5 (Very Heplful) N/A
Family Comfort Kits (New Patient Bag)
Educational Materials
Hero Beads Program
Personal On-site Interactions
Toy Box
Snack Basket
Birthday Celebration
Parent to Parent Groups
Teen Group Events
Get Acquainted Gatherings
Monthly In-hospital Support Lunch
Informal Bereavement Support Group
Parent’s Night Out
Birthday Club
Annual Summer Party
Annual Holiday Party

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* 2. Family Support

Please choose the number of times that you or a member of your family have attended the following

  0 1 2-3 4+
Parent to Parent Groups
Teen Group Events
Get Acquainted Gatherings
Monthly In-hospital Support Lunch
Informal Bereavement Support Group
Parent’s Night Out
Birthday Club
Annual Summer Party
Annual Holiday Party

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* 3. Financial Assistance

Are you aware of the financial assistance program?

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* 4. Have you used the following services?

  Yes No
Emergency Funds
Gas Vouchers/ Grocery Cards
Out-patient Clinic Parking Validation
Supplemental Cafeteria Meal Cards

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* 5. What are the barriers that prevent you from getting financial assistance?

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* 6. Aside from medical expenses, what are the other financial areas that you struggle with?

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* 7. Please choose the number that best represents the impact the services and support from ACCOIN has had on your family and your child during treatment:

  1 (Disagree) 2 3 4 5 (Agree) N/A
Physical and financial barriers to receiving treatment and healthcare were lessened or at times removed
Financial strains on our family during treatment were lessened
The emotional and other support we received helped us cope with our child’s diagnosis and treatment
We were better able to access treatment regularly and on schedule which also helped us and our child develop better relationships with our healthcare providers
Our family was supported and even strengthened during this very challenging time

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* 8. How important is it for you to have the parent to parent relationship?

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* 9. How could ACCOIN improve their services to you and your family?

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* 10. What is your favorite service ACCOIN provides? / What additional support services do you wish ACCOIN could provide? Please provide your name for our records. (Optional)

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