Recipient Intake Form

 
 

Recipient Information

     
 
 
     
     
     
75.101.220.230
All members of Jeffrey Has Heart have signed a Confidentiality Agreements. Your information will not be made public without your consent. Great care is taken to protect the identity of your child. By signing above, you give Jeffrey Has Heart permission to use non-identifying information for purposes of fundrasing, organizational promotion, and data research. In addition to this permission, you also authorize a member of Jeffrey Has Heart to contact you via the methods listed above. Information obatained with protected under HIPPA compliance and regulations.

350 Quorum Drive #101
Trophy Club, TX 76262
(940) 206-3179 i[email protected]