Rare Caregiver Service Request Registration Form

Program Overview

Give an Hour's Rare Disease Program provides support connecting to free and confidential mental health services. To maintain funding for this program, Give an Hour must collect data for anonymous tracking and project improvements. Your personal information will be kept confidential.

Eligibility Requirements

To receive services through the program you must be referred from one of our partner organizations:

Bloom Syndrome Association
Connecting Families UCD Foundation
Fanconi Cancer Foundation
ifopa
IgG4ward!
Lipodystrophy United
TANGO2 Research Foundation
United Porphyrias Association

Client or Referring a client?

Referrer Information:

Referrer Name

Referrer Phone

Referrer Email

Relationship to the Client

Client Information:

First Name

Last Name

Email Address

Phone Number

State

Zip Code

Date of Birth (MM/DD/YYY)

Role

Individual Living with Rare Disease Rare Disease Caregiver Loved one of individual living with rare disease

Primary Language

Will language access services be needed?

YesNo

Reason for seeking services

Current Issues/Concerns (Hold the CTRL key to select all that apply)

Type of Counseling Requested

IndividualCouplesFamilyNot Sure

Insurance Status

I have insurance I can use I have insurance but need probono care I do not have insurance, but can pay sliding scale I do not have insurance and need probono care

Need More Help? Email us at referrals@giveanhour.org