Health Care Access Story Collection Form

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Contact Information

Prefix (Optional) First Name Last Name Suffix (Optional)

Postal Code (Optional) City/Town (Optional) State (Optional)

Email Home Phone (Optional) Mobile Phone (Optional)

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Your Story

Have you been able to access affordable, quality health care in NH? Please share your experience.

Your Experience can Power Change

Are you interested in using your story to make change in New Hampshire? Stories are powerful tools that we can share with lawmakers and the public to influence policy change. Whether it's your own story, the story of someone you know, or stories you see in your professional role, they can make a difference. New Futures can help you develop effective ways to share your story.

𝗜 𝘄𝗼𝘂𝗹𝗱 𝗹𝗶𝗸𝗲 𝗡𝗲𝘄 𝗙𝘂𝘁𝘂𝗿𝗲𝘀 𝘁𝗼 𝗮𝘀𝘀𝗶𝘀𝘁 𝗺𝗲 𝗶𝗻 (please check all that apply):

Sharing my experience with legislators

Sharing my experience in the form of a letter to the editor

Sharing my experience with the media

Sharing my experience on social media

𝗜 𝘄𝗼𝘂𝗹𝗱 𝗹𝗶𝗸𝗲 𝘁𝗼 𝘀𝗵𝗮𝗿𝗲 𝗺𝘆 𝘀𝘁𝗼𝗿𝘆 (check all that apply):

With my first name

With my full name

With my town

Anonymously

Other