COMFORT & CARE APPLICATION

We provide counseling services free of charge to kids battling cancer, Sickle Cell Disease, or any other life-threatening disease or illness.  Our counseling services also extend to patient’s siblings and their parents/guardians.

Parent/Guardian Name *
Parent/Guardian Name
Phone
Phone
Contact Preference
I prefer to be contacted via:
Doctor Name
Doctor Name
Hospital’s Phone Number
Hospital’s Phone Number
Child Life Specialist’s Phone #
Child Life Specialist’s Phone #
Warrior's Name
Warrior's Name
Birth Date
Birth Date
Diagnosis Date
Diagnosis Date
Which family member(s) are you seeking support for?