Ollie’s Branch Heart Family Client Intake

The mission of Ollie Hinkle Heart Foundation (OHHF) is to address the unmet needs of heart families while transforming the future of pediatric heart care. We achieve this by uniting heart families & clinicians through community; providing access without barriers; extending lifelong support; connecting the technical and human-side of care; and promoting education, empowerment, and advocacy.

“Spread Love” is the guiding principle behind our mission, which we extend to both heart families and the clinical care teams that support patients with pediatric heart disease. The stress and challenges faced by families of children with or affected by pediatric heart disease can have significant and lasting effects if not properly addressed. Supporting a family’s mental wellness can better equip them to cope with their child’s diagnosis and care for their heart warrior – benefitting the entire family.

The clinical care team is also an integral part of the child’s and family’s healing. By supporting their mental wellness, they can better cope with the stress and demands of the cardiac unit and provide superior care for all heart warriors.

Ollie’s Branch makes space to speak one’s mind by sharing all of one’s heart regardless of race, color, nationality or ethnicity, age, gender identity or expression, sexual orientation, religion or spirituality, language, national or social origin, ability, and socioeconomic background. We achieve this by wrapping families in love to create a safe space to access mental health support with dignity. Ollie’s Branch is committed to removing barriers to mental health treatment such as availability of resources, accessibility, finances, and stigma.

Ollie’s Branch provides FREE and trustworthy mental health support to heart warriors, heart parents/caregivers, grandparents, siblings, bereaved parents/guardians, prenatal families, and pediatric cardiac healthcare workers at no cost to the recipients. Clinical staff supporting the cardiac unit who have been on staff for at least six months are also eligible to request therapy services. OHHF understands the importance of caring for the mental wellbeing of the entire ecosystem surrounding the child born with or affected by heart disease.

OHHF will recommend a therapist based on the client’s identified criteria and can provide the therapist’s biographical information upon request. It is important that the client feels comfortable with the therapist and that the client confirms the therapist is a good fit for them. Should the recommended therapist not be the right fit, OHHF will provide a second recommendation. Sessions are scheduled directly between the client and the therapist, and the therapist will bill OHHF directly for services.

Heart family clients receive a baseline of 8 sessions with a therapist. We support 8 sessions at onset initially for each person if multiple members of a family want to participate. Services can be accessed while the child is inpatient or outpatient and continue to be available in the instances where the heart warrior passes away. Services are available virtually with some in-person availability. Pediatric cardiac healthcare professionals receive a baseline of 6 sessions. OHHF always reserves the right to extend the number of sessions based on therapist recommendations. Knowing that 9 out of 10 heart warriors will become adults, we offer services throughout the lifetime and families can re-engage in session as new events happen throughout their lives.

OHHF is not part of the relationship between the client and the therapist and will not obtain personally-identifiable clinical information from the therapist. If the client and therapist believe there is something either or both parties would like to share with OHHF, please let us know so we can handle that confidential information with appropriate care.

The therapists to which OHHF refers are a diverse group of individuals who each have a background working with patients dealing with trauma, loss, or resiliency. OHHF performs license verification and OIG clearance on all therapists participating in the program. That information can be provided to the client upon request. OHHF does not guarantee therapists who participate in this program meet all professional qualifications or background check standards. While OHHF has attempted to begin that process for our clients, the process is not complete. OHHF encourages clients to communicate with their therapist in order to resolve any qualification or background needs and obtain appropriate confirmations from the therapist.

OHHF does not provide professional services; rather, our clients’ therapists do. Compliance with any professional laws or requirements are the responsibility of the therapists alone, including compliance with any telehealth or state licensing requirements which apply where the client is located at the time the professional services are rendered. OHHF also defers to the therapist regarding their obligations to ensure their privacy and security responsibilities are met, including the use of telehealth technology.

All of the client’s sessions with their therapist will take place virtually unless otherwise agreed upon between the client and the therapist. The modality of the virtual session can vary based on what is easiest for the client.

OHHF invites you, the client, to accept this free support. OHHF strives to make this process as simple as possible, so please provide the requested information on the following pages that you are comfortable sharing with OHHF. All the information will be kept confidential in accordance with OHHF’s privacy policy. OHHF does not share or sell your information with third parties without your written consent, which OHHF is not seeking here. OHHF uses this information only internally to continually improve the services we provide and to refine OHHF’s efforts to reach families affected by pediatric heart disease.

Please complete the following information to help us make the best possible match to a therapist who can serve your needs.
For questions, email olliesbranch@theohhf.org.

Ollie’s Branch is not a crisis service. If you or someone you love is experiencing a mental health emergency or you are concerned about immediate harm, please call 911 or go directly to the nearest Emergency Department.
Suicide Prevention Lifeline: Dial 9-8-8
National Crisis Text Line: Text HOME to 741741

General Information about the Person Seeking Therapy

Contact Information

(if the client is a minor, please provide contact information for the primary caregiver who will be the point of contact)

Referral Information

Therapist and Session Information

(e.g., do you prefer a specific gender therapist or a particular specialty topic?)
Please note, in-person may not be available for every therapist but we do our best to accommodate requests.
NOTE: General availability indicated here. Further scheduling will occur directly with therapist.
NOTE: General availability indicated here. Further scheduling will occur directly with therapist.

Information about Your Heart Warrior

(if person seeking therapy is the heart warrior, please repeat the information here)

Pre-Therapy Questions

Please provide as much or as little context as you feel comfortable sharing. If you are completing this form on behalf of a minor, please enter answers as they pertain to you, the parent or guardian.

A Little More Information about You

If you are completing this form on behalf of a minor, please enter answers as they pertain to you, the parent or guardian.

By signing below, I acknowledge the following:

● I have reviewed OHHF’s privacy policy and agree with all its terms.
● I choose to participate in Ollie’s Branch as a client.
● I understand this form will be provided via email to the therapist who cares for me under this program.
● I understand OHHF is providing a referral and paying for the therapy that is part of this program. I understand OHHF is not responsible for anything that transpires within the relationship between myself and my therapist.
● I understand that while OHHF reviews licenses for each of the therapists provided to me, OHHF is not providing me with any information or analysis about the therapist’s background or qualifications beyond what is included in the therapist intake form provided only upon request. I understand that my choice of therapists within this program is mine and I am not relying on any promises or assurances about the therapists other than what is provided to me in writing by OHHF.
● I will notify my therapist of my consent for my therapist to bill OHHF directly for up to eight of my sessions.
● I understand OHHF has not provided me with any medical, legal, or tax advice.
(Parent or guardian if client is under 18)

DISCLAIMER: By typing your name above, you are signing this form electronically.
CONTACT US
144 W. Lockwood Ave, Suite201 Webster Groves, MO 63119

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Riley’s Story

Riley was born with tetralogy of Fallot with pulmonary stenosis and complete heart block. He underwent his first open heart surgery at just two months old to repair his heart and a few weeks later had a cardiac pacemaker placed. Since then he has had his pacemaker replaced twice, once after coding in the hospital, and will need additional replacements as he grows.

Riley is happy and healthy living at home with his amazing grandmother, Tracy, and enjoys playing catch, singing and working on PT and OT with Missouri First Steps.

Stella’s Story

Stella was born with hypoplastic left heart syndrome (HLHS) in December 2015 – a CHD that meant she would only have half a working heart and need a series of three surgeries to reconstruct her heart’s anatomy. She underwent her first open heart surgery when she was only two days old, and then additional surgeries at four months old and three years old. Thankfully her gifted surgeons were able to create a stable heart for Stella and she has been the light of her family’s life ever since!

Today Stella is a spunky and smiley five year old that brightens the day of everyone she meets.

Evie’s Story

Evie was born at twenty weeks with hypoplastic right heart syndrome. Her surgeons had planned a series of three surgeries to repair her heart, but unfortunately at birth they discovered her coronaries were missing or abnormal. At one week old, Evie was listed for a heart transplant. While waiting for her hero heart, she was placed on ECMO. At eight weeks old she was blessed with a second chance at life and received a heart transplant!

After eighty-two days inpatient, Evie went home for the first time where her parents are able to enjoy their happy and healthy baby girl.

Emmalyn’s Story

Emmalyn is a year and a half old and was born with Transposition of the Great Arteries (TGA). She had her first surgery at four days old and then again at nine days old. She has since had two angioplasties.

Emmalyn is healthy and thriving. She loves to eat fruit of all kinds, play with all of her animals, play in water, and be outside!

Heart Warrior - financial request

Calvin’s Story

Calvin was diagnosed with a congenital heart defect at fifteen months after the pediatrician noticed a heart murmur, along with other chronic respiratory issues. Calvin has undergone two open heart surgeies in order to re-establish correct blood flow and repair his CHD.

Although Calvin’s CHD will always require specialized care, he is now a happy and thriving four and a half year old. He loves to play golf, play outside, drive his gator and anything to do with trucks, tractors, trains or airplanes.

Allyson’s Story

Allyson is a five year old Heart Warrior. She was diagnosed with a single ventricle heart, heterotaxy syndrome, Noonan’s Syndrome and has survived multiple heart surgeries and a long list of complications over her little life.

Allyson is a preschooler and is so excited to go to kindergarten next year! She has three older siblings who mean the world to her. Allyson is extremely adventurous and her favorite thing to do is go to Target.

This girl is so full of spunk and fight and she is changing the world around her with her story.

KATY LINNENBRINGER
President

Criminal Defense Attorney, Pelikan & Orris LLC

AMANDA SCHMITT
Vice President

SVP, Commercial Banking Relationship Manager, U.S. Bank

PAPPIM STEVENSON
Secretary

Supply Chain Sourcing Coordinator, BJC

LINDA HUNTER
Expansion Chair

Philanthropist

TIM WALKENHORST, CFP
Financial Chair

Financial Advisor, Renaissance Financial

LAURA BOHON
Senior Executive Search Consultant, Benskin and Hott Talent Partners and Heart Parent

NYTASHA TAYLOR
Express Scripts, VP Drug Sourcing

MAGGIE STIEVEN JEWELL
Owner, MKS Designs

MATT SCHMITT
Director, Business Development, Centene Corporation

TEMEKA GAUSS
BJC Healthcare, Advise and Counsel Lead

ANNE PENNICK
Susan G Komen, Product Owner

Ari’s Story

Meet Ari, our spunky vivacious 5-year-old heart warrior, Miss America contestant, and Latoya heart mom extraordinaire. Miss Bey was diagnosed with complex single ventricle heart disease early in her mom’s pregnancy.

Their story has also been complicated by congenital heart disease and cancer. Latoya was diagnosed with breast cancer and underwent treatment before Ari’s birth.

Ari had her first open heart surgery at one week of age and her second at 6 months old. This dynamic mother-daughter duo are the real heroes.

Diego’s Story

Meet Diego, a 14-year-old heart warrior with Hypoplastic Left Heart Syndrome. He has endured multiple surgeries that rerouted his blood flow to maximize his heart’s function. These procedures have been so effective that he has been cleared to play sports and leads a life without constraints.

Diego is an active teen who loves flag football, video games, dad jokes, and walking his dog. His laugh is infectious and always brings an energy and joy that lights up any room. He is the oldest of two brothers, and despite the typical sibling rivalry, he enjoys hanging out with his younger brother and playing video games.

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