Client Testimony - Care Net Peninsula

Client Testimony Form

Thank you for your sharing your story about how Alcove Health has helped you during your pregnancy. Your honest sharing of your experience greatly encourages and informs other women who are facing similar situations and decisions. A release at the end of this form lets us know whether you are allowing us to use your first name or if you prefer to remain anonymous.
How would you describe your life when you found out you were pregnant? (age, living arrangements, etc.)
How did you feel when you found out you were pregnant?
Why did you come to Alcove Health?
What did you experience when you came to Alcove Health?
How has coming to Alcove Health changed things for you?
Additional information you would like to include:
Are there any changes to our services or community outreach that you think we should consider?
Would you return to Alcove Health? 1 being never and 5 being for sure!

1 2 3 4 5
How likely are you to refer Alcove Health to someone? 1 being never and 5 being for sure!

1 2 3 4 5
I give Alcove Health, and its affiliates, permission to use my photo and/or video and/or that of my minor child, if included, all or part of my story to make derivative works, without personal identification unless authorized, for illustration, promotional materials, fundraising campaigns, marketing, and/or promotion of Alcove Health, its affiliates, and/or in any medium. I understand that my testimony may be used to encourage others who are in a similar situation or to encourage financial supporters of the clinic or to promote awareness and fundraising support for the organization.

I understand that "any medium" includes, but is not limited to, things like the internet, social media, YouTube videos, print materials, and the likes. By signing this release, I understand Alcove Health may allow others to use my photo/image, quote, and/or story in any way that Alcove Health could use it.

I waive any claims that I may have arising from such use. There are no restrictions on use unless I have specified them below.
In addition, I give permission to Alcove Health to use (check applicable):

My name (if this is left blank, a fictitious name will be assigned) Name of my minor child/children (if this is left blank, a fictitious name will be assigned) My photograph or video My minor child/children’s photograph or video Permission to use all and or part of my written testimony (your name will not be used, unless notated above)
Your First and Last Name: *

First Name Last Name
Your Signature: *

Clear
Today's Date: *

Month Day Year
Date
If you would like to include any photos to go along with your story, please provide them below. Your story and your images will always be used with the utmost respect.

Cancel of
Should be Empty: