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:
Warrior's Name *
Warrior's Name
Warrior's Birth Date *
Warrior's Birth Date
Warrior's Doctor Name *
Warrior's Doctor Name
Warrior's Diagnosis Date *
Warrior's Diagnosis Date
Which family member(s) are you seeking support for? *