Counseling Services Request

If you are interested in seeking counseling services from one of our licensed social workers, please complete this form. A social worker will reach out to you within two business days. Please visit our partners at Sickle Cell Community Consortium's website to access other mental health resources: https://sicklecellconsortium.org/mental-health-support/

1. Contact/ general information:

Today's date:*

First name:*

Last name:*

Which best describes you:*

Select

If you selected 'other' for which best describes you, please specify:

Diagnosis*

Phone number:*

E-mail address:*

Contact preference:*

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How can we help you?

2. Consent to receive text messages from Be The Match

By selecting “I Agree” below, I authorize Be The Match Patient Support Center to contact me by SMS text message as a way to communicate with me. Be The Match will send me text messages through the Be The Match Patient Support Center outreach texting program to help me, my child or my loved one. I understand that standard messaging and data rates may apply to messages sent by the Be The Match Patient Support Center to my cell phone. I understand that text messages are not a substitute for professional or medical attention. I know that I am under no obligation to authorize Be The Match Patient Support Center to send me text messages as part of this program. I may opt-out of receiving these communications from Be The Match Patient Support Center at any time by texting 'STOP' to (888) 999-6743.

Online Consent: Please select one option below

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3. Demographic Questions

We ask the last few questions so we can design programs and resources that are tailored to your needs and preferences. If you do not wish to answer these question please select 'prefer not to answer.'

Your ethnicity:*

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Your race: Please select all that apply.*

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If you selected 'not listed' for your race, please specify:

If you selected 'not listed' for your highest level of education, please specify:

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