Thank you for agreeing to share your story. Through your participation, decision makers will know how policy choices translate to impact in our state. Please note that the short story you share about the impact of the budget cuts may be posted on our website for public viewing. If you desire, you may indicate that you would like your story to be posted without your identifying information. Your advocacy is essential to ensuring everyone in Connecticut has an opportunity to thrive. Thanks again!

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* 1. Full name

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* 2. Street address

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* 3. City

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* 4. State

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* 5. ZIP code

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* 6. Phone number

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* 7. Email address

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* 8. May we identify your story by name and/or town on our website?

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* 9. Are you willing to speak to the press?

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* 10. Are you a parent or caregiver to children who receive health insurance through HUSKY?

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* 11. Have you received a termination letter from Department of Social Services?

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* 12. How would the loss of health insurance through HUSKY impact the physical health, emotional health, and well-being of the children in your care?

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* 13. How would the loss of health insurance through HUSKY impact the physical health, emotional health, finances, and well-being of your family?

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