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We want to hear from you. Please share your story.

Stories about the real-life experiences of older adults and their family caregivers will help the public, policy makers and others recognize the urgent need for better care.

Are you a family member or friend who arranges, coordinates or provides care for an older adult with multiple chronic health conditions?
Are you an older adult experiencing multiple health problems yourself?
Are you experiencing problems coordinating your own care or the care of a loved one?
Are you seeing numerous physicians, taking multiple prescription medications, and receiving duplicative tests and procedures along with all the other challenges of your daily life?
Do you have difficulty getting clear information from your health care provider?

If so, please take a moment to share your personal story and help support this crucial campaign!

Share Your Story

Question - Not Required - Do you provide care for a family member or friend with multiple health problems who sees more than one doctor and takes more than two prescription medications? Yes
No

Question - Not Required - Are you an older adult with multiple health problems who sees more than one doctor and takes more than two prescription medications? Yes
No

Question - Not Required - Tell us your story. What challenges do you experience with the health care system? Is the current system serving your needs or those of the person you care for? What impact has your experience had on your daily life?

Question - Not Required - Tell us what you need most from our health care system to meet your needs or those of the person you care for:

Question - Not Required - May we follow up with you to hear more of your story? Yes
No

Question - Not Required - Would you like to join our movement of advocates who work together to improve coordination of care in our health care system? Yes
No

Question - Not Required - IF YES, which of the following are you willing to do (check all that apply):

	Email members of Congress, state legislators or other policy makers
	Call members of Congress, state legislators or other policy makers
	Write letters to the editor
	Post your story for the public to read on our website
	Share your story at hearings or to the media
	Join online seminars on various aspects of effective advocacy
	Invite your friends and family to join the Campaign
	Other

Question - Not Required - IF OTHER, please explain:

Question - Not Required - First Name

Question - Not Required - Last Name

Question - Not Required - Street Address 1

Question - Not Required - Street Address 2

Question - Not Required - City

Question - Not Required - State (Abbrev)

Question - Not Required - Zip


*	Email: Required
	Phone Number:
	Gender:
	Date of Birth:	Date of Birth:
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	Remember me. We respect your privacy. Read our policy.

Question - Not Required - Are you Hispanic or Latino origin? Yes
No

Question - Not Required - Your race:

Question - Required - Please indicate what personal information may be attributed to your story (check all that apply):
Please make between 1 and 5 selections from the choices below.

	First Name
	Last Name
	Age
	Race/Ethnicity
	Location (City/State)
	ANONYMOUS. Do not include any personal information with my story!

Question - Not Required - How did you hear about our story project?

Question - Not Required - IF OTHER ORGANIZATION, please specify which one:

The Campaign for Better Care is funded by The Atlantic Philanthropies.