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Share Your Story
mychyp_new
2020-09-30T20:52:11+00:00
Share Your Story
I have a child with chronic pain.
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Your Email
*
How old is your child? (in years)
*
What is your child's gender?
*
Female
Female
Male
Prefer not to say
Other
What state do you live in?
*
If other, please explain below:
What kind of chronic pain is your child experiencing? (choose all that apply)
*
Abdominal Pain
Abdominal Pain
Ankylosing Spondylitis
Arthritis
Autoimmune Diseases
Cancer Pain
Central Pain Syndrome
Chronic Fatigue Syndrome
Complex Regional Pain Syndrome (CRPS)
Crohn’s Disease
Fatigue
Fibromyalgia
Headaches
Irritable Bowel Syndrome (IBS)
Menstrual Pains
Musculoskeletal Pain
Postural Orthostatic Tachycardia (POTS)
Rheumatoid Arthritis
Sickle Cell Disease
Sleep Issues
Sports Injuries
Other
If other, please explain below:
What are some pain related issues that you are currently facing? (choose all that apply)
*
Feeling isolated and/or alone
Feeling isolated and/or alone
Feeling confused
Feeling overwhelmed
Feeling misunderstood by family
Missing school
Poor sleep
Struggling due to financial reasons
Not understanding chronic pain myself
Feeling scared
Feeling frustrated
Feeling misunderstood by doctors
Feeling misunderstood by friends
Missing sports or other extracurricular activities
Experiencing mental health issues (like depression or anxiety)
Struggling due to where I live
Other
If other, please explain below:
What are some pain related issues that your child is currently facing? (choose all that apply)
*
Feeling isolated and/or alone
Feeling isolated and/or alone
Feeling confused
Feeling overwhelmed
Feeling misunderstood by family
Missing school
Poor sleep
Struggling due to financial reasons
Not understanding chronic pain myself
Feeling scared
Feeling frustrated
Feeling misunderstood by doctors
Feeling misunderstood by friends
Missing sports or other extracurricular activities
Experiencing mental health issues (like depression or anxiety)
Struggling due to where I live
Other
If other, please explain below:
Which creative healing technique(s) are you interested in learning more about? (choose all that apply)
*
Acupuncture/Acupressure
Acupuncture/Acupressure
Aromatherapy
Art
Art Therapy
Biofeedback
Cartooning/Animation
Crafting
Culinary Therapy
Dance
Dance Therapy
Gardening
Guided Exercise Programs
Hypnotherapy/Guided Imagery
Massage/Craniosacral Techniques
Mind-based Techniques
Mindfulness/Meditation
Movies/Filmmaking
Pet/Animal-Assisted Therapy
Photography
Theater/Performance Arts
Volunteering
Writing/Poetry
Writing Therapy
Yoga
Other
If other, please explain below:
Which creative healing technique(s) is your child interested in learning more about? (choose all that apply)
*
Acupuncture/Acupressure
Acupuncture/Acupressure
Aromatherapy
Art
Art Therapy
Biofeedback
Cartooning/Animation
Crafting
Culinary Therapy
Dance
Dance Therapy
Gardening
Guided Exercise Programs
Hypnotherapy/Guided Imagery
Massage/Craniosacral Techniques
Mind-based Techniques
Mindfulness/Meditation
Movies/Filmmaking
Pet/Animal-Assisted Therapy
Photography
Theater/Performance Arts
Volunteering
Writing/Poetry
Writing Therapy
Yoga
Other
If other, please explain below:
Would you be interested in joining chyp to explore creative healing techniques and interact with other teens who have chronic pain?
*
Yes
Yes
No
Maybe
Are you interested in getting updates about chyp’s development and services?
*
Yes
Yes
No
Maybe
Is there anything else you would like to tell us?
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