Health journey stories wanted!

Will you tell us about your child's healing journey so that it can be shared with other families who need help? The following survey can take you as long as you want. Some may keep it short and spend 10 minutes, others may choose to share more detail and spend 30 minutes. The insights you share will be kept anonymous unless you grant us permission to use your names and images. Thank you for your time!  If you need help with this form or have a question, please contact us at: support@healingtogether.freshdesk.com

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* 1. What is your email address? (we will use this to contact you about your story).

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* 2. Your child's first name:

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* 3. Please tell us about your child's original symptoms, diagnoses, age of diagnosis, and greatest struggles or challenges.

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* 4. Please describe the "before." What was life like for you and your family when your child was most impacted by his/her diagnosis or symptoms?

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* 5. Please tell us about the most helpful/impactful therapies, approaches, lifestyle changes or healing strategies you have used during your child's healing journey. If possible, please list the top 5 strategies/actions/interventions that you think were most helpful.

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* 6. Please tell us therapies or healing strategies that you have tried that "didn't work," or for which you saw no impact/benefit.

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* 7. Please tell us about your "highest highs" or greatest moments so far from your healing journey.

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* 8. Please tell us about your "lowest lows" or some of the most difficult moments you have experienced throughout your journey.

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* 9. If you have experienced improvements, please tell us about the "after" --what is life like after healing or symptom improvement?

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* 10. Would you be willing to share a photo of your child (sharing a photo is not necessary)?

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* 11. If you choose to share a photo, please upload here.  If you would like to conceal your child's identify, you are welcome to share a partial picture (a shaded face, back of the head, an image of a foot or similar)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 12. What advice would you share with a parent who has an impacted child? What do you wish you had known at the outset of your journey?

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* 13. To help other families see the journey and know that healing is possible, I give Epidemic Answers (DBA Documenting Hope) my permission to share my story.

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* 14. PERMISSION TO SHARE YOUR STORY.  This must be signed by a parent or legal guardian in the case of a child under age 18 or legal guardian in the case of an adult (if applicable).

Parent or Legal Guardian's Full Name

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* 15. Parent or Legal Guardian's Email

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* 16. When sharing the story, what name should we use for your child?

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* 17. PLEASE READ THE FOLLOWING STATEMENT BEFORE SIGNING THIS CONSENT FORM. The undersigned, on behalf of the subject of story, hereby grants Epidemic Answers, Inc. a nonprofit children's health organization, the unrestricted permission, right and license to use the story and to reproduce, exhibit, broadcast, and advertise all or any part of the story in any media chosen by the organization. Epidemic Answers commits to concealing the name of the child or family, if this choice is indicated above. The undersigned is aware that the story maybe published by the organization in print or in electronic publications such as on the website(s) and may be released to other media and others in connection with the promotion or publicizing of the activities of the organization. Epidemic Answers shall own any copyright and all other intellectual property rights in the story. The undersigned waives any demand for compensation and waives any claim to any moral rights or any violation of rights to privacy, publicity or confidentiality under any statute or common law in connection with any use of the story. The organization proposes to act in reliance on this Consent, therefore the undersigned declares it to be irrevocable, and releases the organization from any and all claims, liability, actions or demands whatsoever in connection with the use of the story as provided in this Consent.

By typing your name below, you certify that you are the parent or legal guardian of the child and that you have read and agree to the terms of this agreement.

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* 18. Date signed

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