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) First Last Date of Birth Gender Female Male Your Address Street Address City ZIP Code Which County do you reside in? Erie Huron Ottawa Phone(Required)Can messages be left at this phone number? Yes No What is the best time to contact you? Anytime Morning Afternoon Evening Email Marital Status Married Single Divorced Widowed Other Race White or Caucasian Black or African American Native Hawaiian or Pacific Islander American Indian or Alaskan Native Asian Middle Eastern or North African Hispanic Prefer Not to Disclose Other Caregiver/Emergency Contact Name Phone # Relatonship Name of Oncologist Treatment Hospital Ex: Cleveland Clinic, Firelands Health, Magruder Hospital, The Bellevue Hospital, Seidmen Cancer Center, Fisher-Titus, Mercy Health, Promedica, etc. Type of Cancer Stage Date of Diagnosis Are you receiving? Chemotherapy Radiation Immunotherapy Other Therapy Start Date Will you be transporting yourself to treatment? Yes No How were you referred to or hear about Cancer Services? Ex. Physician Office, Hospital, Nurse, Social Worker, Friend, Family, Facebook, STS Bus, Online, Other. Are you currently working? Full Time Part TIme Disabled Laid Off Unemployed Retired Other If you are currently working, where do you work? Current Total of Annual House Income $0-$20,000 $20,000-$25,000 $25,000-$30,000 $30,000-$35,000 $35,000-$40,000 $40,000-$50,000 $50,000-$60,000 $60,000-$70,000 $70,000-$80,000 Over $80,000 Information has no effect on eligibility for Cancer Services, but it is needed for grant reporting purposesFamily Income Source Salary Social Security Pension Retirement Savings SSD (Disability) Short or Long - Term Disability Unemployment Family or Friend Support Other Please check all that applyNumber of people in household Do you have health insurance? Yes No If you have health insurance, is it? Medicare Medicaid Private Other If private, what kind? Annual Deductible $ Are you a Veteran? Yes No Please check all benefits that you are currently receiving: WIC Veteran's Administration (VA) Job & Family Services Other What agencies are you currently working with? example: Serving our Seniors, Hospice, Cancer Tees Me Off, etc. What services are they providing you with? Cancer Services' Programs Requested Nutritional Supplements Transportation Mileage Reimbursement Prescription Assistance Medical Supplies Medical Equipment Wigs & Mastectomy Items Educational Resources Please check all that applyHow do you feel Cancer Services can help you best? I give Cancer Services permission to speak to my medical provider, social worker, or other support staff.Client Signature or Caregiver Signature(Required) Please typeDate(Required) MM slash DD slash YYYY 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.Client Signature or Caregiver Signature(Required) Please typeDate(Required) MM slash DD slash YYYY
