Hope for HIE Book Interest Form

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Thank you so much for your interest in sharing your story for Hope for HIE's book documenting the narratives of HIE families, healthcare workers, and researchers within our community! As you probably know, many HIE families express the desire to hear the stories of others who have endured similar struggles as them. We hope that this book can be a way to fulfill this need and show families that they are not alone, as well as spread awareness about HIE. After you complete this survey, Simran will reach out to you via e-mail with to schedule a 1-hour interview over Zoom. For any additional questions or concerns, please e-mail simran@hopeforhie.org.

Email *

Name *

Relationship to HIE Child *

Parent

Caregiver

Extended Family Member

Other:

Age of HIE Child

0-3

4-6

7-10

11+

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Where you live (Town, State, Country)

Which of the following best describes you?

White

Hispanic, Latino, or Spanish origin

Black/African American

Asian

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

Other:

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Are you a loss parent?

Yes

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Are you be able to meet during the month of June for a 1 hour interview over Zoom? *

Yes

Would you also be interested in submitting photographs, artwork, or poems that represent your journey for the book?

Yes

Maybe

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Submit

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