C.O.P.E. Program Intake Questionnaire
Dear Participant,

Thank you for your interest in participating in the program, Community of Parents Empowered (C.O.P.E.) given by Advancing Sickle Cell Advocacy Project Inc., (A.S.A.P.). This program is offered to families in Broward and Miami Dade.
We are kindly asking that all parents complete this questionnaire so we can assess and evaluate the social and mental health care needs of parents and caregivers that take care of children with Sickle Cell Disease. This information will help us improve and develop programming that benefit parents and families that have children with Sickle Cell Disease. All the information you share with us will be kept confidential and will not be shared with anyone without your consent. Participating in the survey is voluntary and if you choose not to answer the questions this will not affect your relationship with ASAP, or any of the people apart of the C.O.P.E. program.

Please answer all the questions to the best of your ability.

Program will begin April 2026


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Email *
Full Name (First & Last) Name of parent/guardian completing this form *
Sickle Cell Warrior Date of Birth (Month Date Year) *
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Parent completing registration Date of Birth
(Month Date Year) 
This information is collected for data purporses only.
 *
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Please include best telephone contact # *
Please include your email address *
What county do you live in *
What is your race/ethnicity? (Check all that apply)
What is your Primary language? *
What is your marital status?
Clear selection
How many people reside in your household?
1. Have you or your child been diagnosed with sickle cell disease? *
2. How old is your child(ren)? *
3. Does your child attend school or daycare? What grade level? *
Required
4. What type of sickle cell does your child have?   *
Required
5. Select which hematologist center your child is seen by. If not listed enter in Other.  *
6. How many times in the last 12 months did your child require an Emergency Room visit? *
7. How many times in the last 12 months did your child require a hospitalization? *
8. Is your child on daily medications? If Yes enter medication name in Other. *
9. How do you manage your child's daily pain episodes at home?
10. How many times in the past 12 months have you missed work because your child was sick? *
11. Are you comfortable speaking to your child's healthcare provider about pain episodes and sickle cell triggers?
Clear selection
12. Who is your support system?
13. Do you have support from a community based sickle cell organization or support group?
Clear selection
14. Are you in need of support with any of the following services?
15. Are you currently seeing or have seen in the past a mental health provider related to the stress of being a caregiver?
Clear selection
16. Does your child have health insurance? 
Clear selection
17. Has caring for your child with sickle cell disease hindered you from staying employed? 
Clear selection
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