Portrait Gift Session Request
For Pediatric Cancer Patients (Serving little warriors, survivors, children/teens in remission)
Your Name
*
First Name
Last Name
E-mail
*
Phone Number
*
Include ext.
Is this session for your child/family or are you referring someone?
For my child and our family
It is a referral
What is the name of with child or teen your are referring and how old are they?
The parent's names and contact info
Please tell me a little bit about your family or the family you are referring
Please check one
Warrior status (He/She is currently fighting the battle)
Is currently in remission
Pediatric Cancer Survivor
How many members are in the family?
2
3
4
5
How long has this little warrior been fighting the battle and approximately at what age was he/she diagnosed?
If you are the caring soul who is referring the family, who should I contact about scheduling a consultation for a Gift Session?
I have questions for you, so please contact me first.
It is ok to go ahead and reach out to the family, because I have already let the family know that I have referred them.
If it is alright to contact the family? If so, which would be the preferred method?
Email
Phone Call
Text
How did you hear about my Gift Sessions
If you were referred by a friend please let me know so I can thank them!
Thank you for the referral! Once I check out the questionnaire I will contact you to let you know what the next step is.
Sincerely, Cindy - Memory Box Photography - 916-834-7020
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