Connect Ovar Coffee Podcasts: 2022

Ovarcare form image

Via OvarCare Counseling we are pleased to offer:

Up to 6 sessions of support for up to 6 months
Meetings by phone in any location in the U.S.
Supportive services to OvarCare grant recipients
Information, resources, referrals as needed and requested

Our OvarCare counseling sessions are designed to provide support through the journey of Ovarcoming Ovarian Cancer and are not deemed to be psychotherapy services. Our members are ready to provide compassionate and meaningful support via active listening, providing gentle guidance in navigating the often-challenging course of diagnosis, treatment and survivorship, and in providing effective tools and resources to Ovarcome.

Please complete the fields below to register for our counseling program:

We are here to Ovarcome with you. Welcome to our safe and friendly space.

This is a complimentary service as part of our OvarCare Program and is currently available in English only.

Information

Name: *

Date of birth: *

Email Address: *

Address: *

Do you consent to receiving text messages from your OvarCare Support Services?: *

YesNo

Share with us the best way to reach you: *

EmailPhoneText MessageAll of the above

Primary Phone Type: *

MobileLandline

Please indicate your time zone: *

Eastern TimeCentral TimeMountain TimePacific Time Hawaii-Aleutian Time

What do you wish to accomplish from these support sessions? Please share your personal goal: *

Please carefully review the acknowledgements below:

1. OvarCare support services are designed to provide emotional and informational support and is not intended to provide any medical guidance. It is also not intended to provide psychotherapy, crisis management critical mental health issues2. You will be offered up to 6 counseling sessions for up to 6 months as part of this program. You will be contacted via the information you provide to us. Ovarcome is not responsible to maintain privacy of information if provided outside of the channels indicated on the form3. You agree to indemnify, defend, release and hold harmless Ovarcome, their employees, officers, directors, agents, successors and assigns, against all liabilities, claims, causes of action, damages, judgments, costs or expenses, including attorney's fees, caused by, resulting from or which arise in connection with your participation in OvarCare Support Services Program

Acknowledgement of My Consent

BY CHECKING THIS CONSENT, I CERTIFY THAT:

I have carefully read and consent to the terms and conditions stated herein.

Name: *

Date: *

Connect Ovar Coffee Podcasts : 2022

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