How Can We Help?

Please fill out the following information to request help from a JKPPA volunteer.

1. First Name

2. Last Name

3. Email Address*

Call for assistance in establishing an email address if you do not already have one

4. Phone Number

5. What is your preferred method of communication?

Telephone

Electronic

6. Street Address

7. City

8. State/Region

9. Zip Code

10. Client Concern Refers To

Self

Parent

Spouse

Sibling

Child

Other Relative

Friend

11. Birth Year

12. Please share what concern you have?

(client concern type)

Medical

Insurance

Legal

Financial

Social Services

Mental Health

Other

13. When did the concern begin?

Month/Day/Year

14. Briefly tell us about the concern:

15. How does the individual identify? (check all that apply)

This question is optional.

Female

Male

Non-binary

LGBTQ+

Heterosexual

Prefer not to answer

Other

16. What's the individual's race/ethnicity? (check all that apply)

This question is optional.

American Indian/Alaskan Native

Asian

Bi/Multi Racial

Black/African American

Hispanic/Latinx

Native Hawaiian/Other Pacific Islander

White/Caucasian

Prefer not to answer

17. Name of the health care provider/facility/other organization involved

18. Location of the health care provider/facility/other organization involved: City

19. Location of the health care provider/facility/other organization involved: State

20. How did you hear about JKPPA?

Brochure

Referral

Social Media

Community Outreach Event

Relationship to JKPPA representative

Internet Search

Print/Digital Media

JKPPA will not directly reach out to health care providers to obtain protected health care information. By providing private information or access to private information to JKPPA and its partner volunteers you understand that we intend to use the information to assist you and to promote the mission of JKPPA. Although JKPPA is not a covered entity for HIPPA purposes, we use our best efforts to maintain the privacy of health information and will not voluntarily make disclosures to others.