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Intake Form
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Eligibility
Making Headway Foundation is a non-profit dedicated to families impacted by childhood brain or spinal cord tumors. Have you or your child been diagnosed with a primary or secondary pediatric brain or spinal cord tumor?
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Yes
No
Would you like to continue?
Due to our mission, most of Making Headway's programs are restricted to families impacted by a childhood brain or spinal cord tumor. However, if you want to continue, please feel free. Would you like to continue?
Yes
End Session
Family Details
Child's (Patient) Full Name
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Child's (Patient) Date of Birth
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MM slash DD slash YYYY
Parents Name (if child under 18)
Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Email
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Phone (Primary)
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Phone (Secondary)
Diagnosis
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Services
Please check all the services you may be interested in
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Therapist
Psychiatrist
Educational Advocacy
Free Events
Personal Family Liaison
No services at this time
Other
Other service
Name of hospital for treatment
NYU
Memorial Sloan Kettering
Cohen's Children (Northwell)
Columbia/NY Presbyterian
Other
Other hospital
Additional Details for Requested Service: Therapist or Psychiatrist
Name of person in need of support
Are you open to telehealth?
Yes
No
Not sure
Additional Details for Requested Service: Educational Advocacy
Name of person in need of support
Name of School
Grade
Does your child already have an IEP?
Yes
No
Not sure
Consent
I hereby give permission for the exchange of information, both verbal and written documentation, from any hospital to members of the Making Headway Ongoing Care Team, Staff, as well as the medical, nursing, teaching, neuropsychology, psychotherapy and social work professionals involved in the child's care as agreed to below. The purpose of and the need for this information exchange is for continuity of and enhancement of care and treatment. From the date signed, the permission to share medical information will be valid for five years and permission for contact information will be ten years. The signer can revoke this authorization at any time, by submitting a request to dan@makingheadway.org or directly to the hospital. Your data will never be sold.
Consent 1
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My Child’s demographic and contact information (address, phone, and email).
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Consent 2
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My Child’s health summary, including any medical conditions (history, lab tests, notes, reports, or images) and/or my Child’s neuropsychological or psychological information (exams, reports, notes, medications, drug use), educational reports or information (including tests and evaluations)
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Consent 3
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Only for families requested free psychological or psychiatric services. I give permission to my family's medical insurance information, including copies (front and back) of the insurance card, and the policy holders full name and their date of birth. This will be used to submit insurance claims on behalf of Making Headway. Families will never be charged for any Making Service under any condition.
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Consent 4
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I give permission to my child's current or previous school district, as appropriate to communicate with and release any information and copies of records to the Making Headway Ongoing Care Team, including the LIAC, Susan Luger Associates, or other Ongoing Care Team members, concerning my child. I also agree that the Making Headway Foundation team member can share internally any diagnostic health information about any patient being seen (including the child, sibling, parents, or other care-takers).
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Signature
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Date
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.
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