Patients and families

Support group consent

Thank you for choosing to participate in a Children’s Wisconsin support group. Please read the following details and submit your registration to attend your group. Your information is only shared with your group leader and the support group coordinator.

Program Disclaimer

Children’s Wisconsin recognizes that support groups are one method families use to learn about having a child with special health care needs. A support group is a group of people with common experiences or concerns who provide each other with encouragement and advice.

Registration

We ask that you please complete the form below. We may utilize the contact information to follow up with you once or twice per year with a brief survey. It is our intent to ensure that groups sponsored by Children’s Wisconsin meet the standards and expectations of the children and families we serve. These surveys allow us to understand your experience, what you value about this opportunity, and how we might improve in the future.

Personal information

Parent name (First and last name)

Relationship to patient

Address 1

Address 2

City

State

Zip code

Your phone number (Mobile or Home)

Your email address

Support group

Select one:

Please list any specific topics or questions you have or would like to see discussed during the support group

If All Ears Support Group selected

Number of child(ren) with hearing loss

Age of the child(ren)

Type and degree of hearing loss (if known)

Hearing aid manufacturer (if known)

Form of communication (Oral, American Sign Language, Both)

If Mended Little Hearts selected

Age of child with CHD

Type of heart defect

Do you receive care or services at Children’s Wisconsin Herma Heart Institute? Yes No

Would you like to be connected with a support parent that has had a similar experience? Yes No

Authorization to use image/information in public communications:

Scope of Service Diagnosis and treatment of depression or other psychiatric conditions requires trained medical professionals. The information and support found in this group is intended to be used for peer-to-peer support, and not as a substitute for professional treatment. If you need information or resources for professional services you may seek a referral from your primary care physician. You may also reach out to professionals at the Daniel M. Soref Family Resource Center at Children’s Wisconsin. The Center can be reached by calling 414-266-3169 or by walking into the main hospital lobby of Children’s Wisconsin across from the gift shop. They can assist you with finding appropriate community resources and providers to meet your needs. Children’s Wisconsin or any of its support group facilitators or members do not make any warranty or guarantee, either expressed or implied, regarding the completeness, accuracy or currency of the information shared in the context of the group, nor its suitability for any particular purpose. Therefore, you should not rely upon any of the information obtained in the context of this group as a substitute for consultations with qualified health professionals who are familiar with you and/or your child. If you have questions about this group, or the type of support it does or does not provide, please ask the group sponsor and/or facilitator for more information.

I have read and understand the statement describing the services provided by this group. Yes

Signature and Date Authorization may be terminated at any time by contacting FamilyPartners@chw.org or calling the Family Partner Program at (414) 266-5699.

In this section