Client Intake Form Online Form

Client Intake Form

Please complete all of this form. Your personal and household information is kept confidential. Services are provided free of charge for qualifying cancer patients residing in Erie, Huron, and Ottawa counties and are made possible by the generosity of local donors and foundation grant funding. For more information, please visit our website or Facebook page. All information is required. If anything is left blank we will call you to gather more information.

Your Name(Required)
Your Address
Which County do you reside in?
Can messages be left at this phone number?
What is the best time to contact you?
Marital Status


Ex: Cleveland Clinic, Firelands Health, Magruder Hospital, The Bellevue Hospital, Seidmen Cancer Center, Fisher-Titus, Mercy Health, Promedica, etc.
Are you receiving?
Will you be transporting yourself to treatment?
Ex. Physician Office, Hospital, Nurse, Social Worker, Friend, Family, Facebook, STS Bus, Online, Other.
Are you currently working?

Current Total of Annual House Income
Information has no effect on eligibility for Cancer Services, but it is needed for grant reporting purposes
Family Income Source
Please check all that apply
Do you have health insurance?
If you have health insurance, is it?

Are you a Veteran?
Please check all benefits that you are currently receiving:
example: Serving our Seniors, Hospice, Cancer Tees Me Off, etc.
Cancer Services' Programs Requested
Please check all that apply

I give Cancer Services permission to speak to my medical provider, social worker, or other support staff.

Please type
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Equipment Loan Agreement - I agree to return the equipment/materials that I have borrowed from Cancer Services in good condition. I will not hold Cancer Services liable for any injury that I may sustain while using the equipment that they have provided to me.

Please type
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