SentWell Request For Care Form - Family -(Novo)
Please complete this form to help us prepare for your visit and provide the best care possible while you are with us.
Email address *
Contact Information
Names and Ages of Parents *
Your answer
Phone Numbers (with country code): *
Your answer
Positions and Type of Work
Your answer
City, Country or Region Where You Serve:
Your answer
Passport Country
Your answer
Names and Ages of Children
Your answer
Describe the Type of Schooling for Each Child (Local, Private, International, Home-schooled, etc.)
Your answer
Care Request
Please describe why you are seeking care:
Your answer
How urgent is your current need? *
Minor Concern
Extremely Urgent
How distressed are you about your current concern? *
Very Little
Extremely Distressed
In the past month, how would rate how your marriage is doing? *
Extremely poorly
Extremely well
In the past month, how would rate how your children are doing? *
Extremely poorly
Extremely well
Please share with us any particular needs of your children that would be good for us to know:
Your answer
What do you hope to gain from receiving care?
Your answer
Have you ever received care for this concern? If so, when and with whom:
Your answer
How does your family relax and recreate best?
Your answer
* Privacy Notice *
In compliance with the General Data Protection Regulation (EU) 2016/679, we are informing you that the data you provide in this form to the SentWell team will be treated with confidentially. We will keep your data for the purposes as stated in this form until a time when we hear from you that you would like your data removed. We will not share nor sell your information to anyone. You can contact the Delegation of Data Control at: info@sentwell.org if you wish to alter, remove or limit your data. Thank you.
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