SentWell Request For Care Form - Individual - (Non-Novo)
We provide services based on both specified needs and staff availability. We will try to respond as promptly as possible.
Email address *
Contact Information
Name(s) (First and Last) *
Your answer
Phone (with country code): *
Your answer
Position and Type of Work
Your answer
Age(s) *
Your answer
City, Country or Region Where You Serve: *
Your answer
Passport Country
Your answer
Sending Agency *
Your answer
How did you hear about SentWell *
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
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
I'm seeking care because... *
We request a 50€/hour donation for our services. We do not want anyone to go without care for financial reasons. If this is not feasible for you, please indicate you would like to discuss alternatives:
* 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 complete confidentiality. 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: if you wish to alter, remove or limit your data. Thank you.
Never submit passwords through Google Forms.
This form was created inside of Novo. Report Abuse - Terms of Service