Heart to Heart Ambassador Support Request























































Please provide us with an emergency contact



















By signing this form, I acknowledge that this confidential medical information (including name, age, diagnosis) pertaining to me may be released to ACHA's "Heart to Heart Ambassador" assigned to contact me. This information will be transmitted by ACHA staff to the Heart to Heart Ambassador and will be kept in their strictest confidence. I understand that there are a few circumstances which may limit the confidentiality between an Ambassador and myself. These circumstances are listed below:

  • Your health or personal safety is at risk
  • You are a threat to another individuals' health or safety
  • There is a disclosure of physical, sexual or emotional abuse or neglect, which involves a minor, an elderly individual, or a person with a disability.

I also understand that the role of the Heart to Heart Ambassador is to offer basic support, information and referral. Furthermore, I understand that the Ambassador does not replace professional help, attempt to provide psychotherapy or take the place of a physician. I know that ACHA's Ambassadors do not give medical advice, lend money or provide counseling. Finally, I am aware that this relationship is short term in nature, not to exceed three to six months.

Should an appropriate match not be available through ACHA's Heart to Heart program, you will be contacted by the Program Coordinator with other options for support.

I have received and read ACHA's Heart to Heart program description and realize the following:

  • An Ambassador is not a therapeutic counselor
  • An Ambassador does not dispense medical advice
  • An Ambassador is not expected to be a member's main source of support

I will not act on any perceived medical advice from the Ambassador assigned to me without consulting my physician






Thank you for your interest in the Adult Congenital Heart Association's Heart to Heart Program