Share Your Chronic Illness Story

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Our Center for Chronic Illness (CCI) support groups and health education programs offer a great way for participants to connect with one another and share their experiences of living with chronic illness. We recognize that some individuals do not have the opportunity to join our programs or may not feel comfortable sharing their full stories in the small group setting. This also helps us to understand how we can better support or grow our offerings.

We have created this form to give individuals an opportunity to share their experiences of living with and being impacted by chronic illness, and how CCI has helped them. Caregiver and loved one stories are also welcome. Please only share as much as you feel comfortable sharing. Thank you for being willing to share your story with us!

If you have any questions, please reach out to info@thecenterforchronicillness.org.

What is your name? (please leave blank if you'd prefer to be anonymous).

Have you attended a CCI support group or educational program?

Yes

I'm on a waitlist for a support group

I plan to in the future

Clear selection

What chronic illness(es) do you live with?

How has your chronic illness impacted you, or what do you want others to know about it?

How have CCI support groups or resources helped you in living with chronic illness?

Sharing the stories of how CCI has helped people living with chronic illness helps us spread the word about our programs and generate support so that we can expand our offerings. Would you be willing to let us share your story?

This may include on our website, via e-newsletter, social media, or during a future CCI event. We will never share anything without your permission and without giving you a preview first if identifying details are used. Otherwise, let us know if we can use any quotes you've shared here anonymously.

Yes, I'd like to share my story with my name and potentially photos (we will follow up with you)

Yes, I'm OK with sharing my story anonymously/without my name or photo

No, I don't want anything to be shared outside of CCI staff and volunteers

Other:

If you said yes to the previous question and are OK with someone from CCI following up, please add your name and email here. Thank you!

What is your age range?

under 18

18 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75+

Decline to Answer

Clear selection

Do you identify as a member of the LGBTQIA+ community?

Yes

Prefer not to say

Clear selection

Which of the following best describes your race/ethnicity?

Asian or Pacific Islander

Black or African American

Hispanic or Latino/Latinx

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

Prefer not to say

Other:

Clear selection

Submit

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