Better2getherRVA

We’re happy that you’ve found us on your journey seeking support for your family while caring for your child. It is the mission of Better2gether RVA is to provide comfort, support, and guidance to families of children with medically complex illnesses, whose needs are not addressed by existing organizations. Please complete the below application and a member of Better2gether will make contact with you.

 

Family Application

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What is/are your child’s diagnosis(es)?*

How long has your child been ill?*

How many Inpatient hospital stays has your child had in the past 6 months?*

How many Specialists (Outpatient Specialty Clinics) does your child see for his/her medical condition? Please list them.*

What is the average number of times your child has visited these Specialists PER MONTH, in the last 6 months?*

What other treatments or therapies does your child receive outside of a medical setting (home, therapy center, etc)?*

When did you realize that your child’s illness was chronic and complex?*

Upon realizing your child’s illness was chronic and complex, what non-medical resources did you need first?*

What have been your biggest challenges as a family?*

What tangible and intangible resources would make the biggest difference in the life of your child and family today?*

On a scale of 1 to 10 rate how well supported you feel caring for a child with a chronic complex illness?*

Is there anything else that you think we should know about your child or family?*

Name and Date of Birth of everyone living in your home?*

Upcoming Appointments: (Location, Date, Time so we can meet you to deliver Better Bags)*

How did you hear about us?*


 

Thank you for taking a few minutes to answer the above questions to help us continue to make sure that Better2gether is working to meet the needs of the families we seek to support.

 

Better2gether RVA does not discriminate on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief.

 

Better2gether RVA values your privacy. We will keep your information confidential. Information about you, including your name, address, phone number, and email address will not be shared with anyone outside the organization without your expressed permission.