NEWLY DIAGNOSED T1D FAMILIES

If you are newly diagnosed with Type 1 Diabetes in Connecticut, Rhode Island or Western Massachusetts, we understand the challenges and medical expenses that come with this diagnosis. We are committed to supporting you and your family during this journey. Please complete the form, and someone will contact you via email soon.

Name of parent - First name

Name of parent - Last name

First name of child

Age of child

Gender of child

Street Address

City

State

Zip Code

Cell Phone Number

Email

Endo Provider

CCMC

Yale

Other

Date of Diagnosis

Month

Day

Year

Is your child using an insulin pump? If so, which pump?

Is your child using a continuous glucose montitoring system (CGM)? If yes, which version?

Dexcom G6

Dexcom G7

Freestyle Libre 2 (or 2 Plus) - same size

Freestyle Libre 3

Do you have celiac disease as well as Type 1 Diabetes?

Siblings ages

What shirt size is the T1D?

Is your family economically disadvantaged, receiving government assistance or income at poverty levels? If you answer no, you have completed this form after you click SUBMIT and someone will outreach you soon. If yes, the form continues.

Yes

No

How many family members live in your household?

Are you receiving government assistance?

Yes

No

Are one or both parents unemployed or income at poverty levels? What non-medical items have you purchased for your T1D since diagnosis? What items do you wish you had funds to purchase?

We have the following items available as supplies last for economically disadvantaged families - please check box next to each item that you haven't purchased yet:

Valued vendors in the Type 1 community who support our program through discounts or other contributions:

Spibelt

Pain Care Labs

4imprint

4all Family

Frio

PumpPeelz

Sugar Medical

Glowcose

Custom Type 1

Pip Diabetes Care
Vial Safe

Buzzy

Information provided by the following:

Finding Smiles Coaching

Touched by Type 1

Lauren's Hope

Camp Surefire

Breakthrough T1D

Diamyd

Connor Parkinson