Caring Connections Mentor Request & Release Form

Caring Connections is a group of trained volunteer mentors. This unique program offers guidance and support by pairing caregivers with compassionate mentors who have been through similar lived experiences.

When you are a caregiver for a child, you may feel overwhelmed, afraid, or alone. Connecting to other people that have gone through this journey before can offer guidance, strength, and hope.

Caregivers and mentors can connect through ways that are comfortable for both parties. Interactions may take place over the phone, video chat, text message or email.

Please complete the application below to request a mentor.

Release of Information:
I give my permission for SSM Health Cardinal Glennon Children's Hospital Parent and Family Advisory Program to release my name, telephone number and the information I have provided on this form to a Family Caring Connections Mentor as part of the SSM Health Cardinal Glennon Children's Hospital Caring Connections Family Mentor Program. SSM Health Cardinal Glennon Children's Hospital Family Caring Connections Mentors have been vetted, screened and trained by the Parent and Family Advisory Program and Volunteer Services. I understand that failure to participate in this program will not affect my child’s ongoing care or treatment. I understand that disclosure of information as required by federal, state, or local law [such as child abuse and neglect, or harm to self or others] will be shared with the Patient Experience Specialist and the clinical team’s social work partner.

I may end participation in this program at any time by contacting the Patient Experience Specialist at SSM Health Cardinal Glennon Children's Hospital at any time.

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