WCRC General Client Intake

Welcome! If you are new to WCRC, or have not completed an intake form previously, please fill out this form. It will take about 10-15 minutes to complete. Your answers will help us understand your needs and best connect you to our services.

Your privacy is very important to us. Please know that we will not share any information provided in this form without your consent.

Please note:
- We do not provide crisis support services.
- We serve residents of Contra Costa and Alameda counties. If you reside outside this area, we are happy to provide referrals to other resources. Please call us at 510- 601-4040.

Queremos trabajar con usted para conectarle con nuestros servicios. Si desea recibir ayuda en español, llámenos al 510-809-0217 o envíenos un correo electrónico a wcrc@wcrc.org.

Overview of the Programs We Offer:

Patient Navigation: WCRC's patient navigators assist clients in overcoming obstacles to quality cancer care. They provide resources to clients in active treatment with challenges related to food, transportation, financial assistance, medical related expenses, etc. Navigators can also help identify resources that can support a client’s caregivers and family.

Free Therapy: WCRC’s Free Therapy Program offers women, nonbinary individuals, and caregivers earning less than $45,000 annually with 1:1 counseling support related to cancer.

Support Groups: WCRC offers a variety of groups that provide emotional support to clients of diverse backgrounds and stages of the cancer journey, including caregivers.

Wellness Programs: Our wellness workshops give our clients the opportunity to move their bodies (e.g. yoga), be creative (e.g. art, creative writing), learn about nutrition (e.g. cooking classes), and expand their spirits (e.g. meditation) in supportive in-person, virtual or hybrid formats.

Financial Assistance: WCRC has a limited supply of emergency Financial Assistance funds available. To learn if you qualify and how to apply, please visit: www.wcrc.org/practical-assistance
WCRC Eligibility Screening

Before you begin your intake form, please complete these questions to confirm you are eligible for our services.
Do you reside in either Alameda or Contra Costa Counties?
Have you or a loved one received a cancer diagnosis (current or in the past)?

Are you completing this form on behalf of someone else? If so, please fill in the following four questions. If not, please leave blank and skip to the Basic Information section.
Name of person completing this form:

First NameLast Name
Phone Number of person completing the form:

Area CodePhone Number
Email of person completing the form:
example@example.com
Relationship to client:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Basic Information

We collect the following information to help us best understand our clients identities, lived experience, and the demographics of our client community overall so we can make the best decisions about how to allocate our resources and improve our services. As with all the information in this form, the responses are confidential and will not be shared.
Please select the program you are interested in:

Other
Client Name

First NameLast Name
Client is a:

Other
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client's Primary Language
Primary Language Spoken at Home:

Other
Date of first contact with WCRC (in person, online, or on the phone)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What county do you reside in?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email (if none please type N/A)
example@example.com
What is your preferred way to be contacted?

Other
If you selected phone, is it OK to leave a voice message?
Cell or home?
Alternate Phone (cell or home)

Area CodePhone Number
Emergency Contact Name and Relationship to Client
Emergency Contact Phone Number

Area CodePhone Number
We want to make sure you stay connected. Please choose how you would like to receive WCRC information: (check all that apply)
Email (if no email, please enter, "unsure or does not apply")
example@example.com
How many people are living in client's household? (Please only include those that are reported on client's tax return or other official documents; not roommates or guests)
Of the number reported above, how many are dependents (under 18)?
Client's annual household income is:
Race (check any that apply)

Other
Ethnicity (check one)

Other
Gender (check any that apply)

Other
Gender Pronoun (check any that apply)

Other
Sexual Identity

Other
About Your Cancer Diagnosis & Treatment

Note: If you are a caregiver, please complete this form on behalf of the person with cancer you are caring for. If you are a social worker or otherwise completing this form on a client's behalf, please complete the cancer-related questions for them.
Type of Cancer (if you have received multiple diagnoses in the past, please list the current or most recent type):
Date of Diagnosis:
Current Stage of Cancer:
Metastasis: did the cancer start in one area and spread to another?
If yes, location of metastasis (if known):
What treatments are you receiving or have you received for your diagnosis? Please check all that apply:

Other
Is this your first time diagnosed with cancer? Please check any past treatment that apply:

Other
Start Date of Current Treatment (if known):
Start Date of Past Treatment (if known):
What integrative/alternative treatments are you currently receiving or have you received (check any that apply):

Other
Treatment Details
Do you have an oncologist?
If yes, provide oncologist name and hospital/cancer care location (include city):
Do you have a social worker?
If yes, social worker name and location:
Please select your primary medical Insurance:

Other
Medical plan name: (e.g. Kaiser, Blue Cross-Anthem, Aetna; if Covered California, note name of insurance provider.)
Where is the primary place you receive medical care:

Other
If you have secondary medical insurance or a secondary provider, please list these here:
Is this your first time diagnosed with cancer?
If no, please indicate what type of cancer you were diagnosed with in the past:
Please share any treatment details:
WCRC works closely with the Charlotte Maxwell Clinic, a free women's clinic in Oakland that provides integrative therapies like acupuncture, massage, bodywork and movement therapy for women with cancer. If you are interested in being referred to Charlotte Maxwell Clinic to learn more about their services, please check the box below:
WCRC also partners with Bay Area Cancer Connections and can assist you with accessing wigs or prostheses. Is this something you are interested in learning more about?

Other
Your Vital Conditions

The answers to these questions will help us understand more about your needs and which of our programs and services can best meet them.
Do you have stable housing?
If no or unsure, current situation:
Would you like assistance accessing housing resources?
Annual household income below $30,000?
In the last six (6) months, have you struggled to access enough healthy food for you and your household?
In the last six (6) months, have you run out of healthy food or had limited access to healthy food?
Would you like assistance accessing food resources?
Please select the WCRC program(s) you are interested in:
Please select any of the following supports you'd like to learn more about:
Screening Support

Other
Diagnostic Support

Other
Treatment Support

Other
Financial Support
Emotional Support
How did you hear about WCRC?

Other
Would you like to sign up to receive:
Practical Support

Other
Transportation
WCRC wants to meet every client where they are. If there is anything else we should know about you or your circumstances, or any specific supports or services you are looking for, please let us know here, and we will follow up with you:
Women’s Cancer Resource Center
wcrc@wcrc.org ✦ 510.601.4040
2908 Ellsworth Street, Berkeley, CA 94705

Thank you for your interest in Women's Cancer Resource Center. Unfortunately, we are only able to serve residents of Alameda or Contra Costa County with a current or previous cancer diagnosis (or their caregivers). If you would like some referrals to services outside of our region or have other questions, please call our help desk: 510-601-4040. Thank you!
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