Client Intake_BLANK

Date

MonthDayYear
Date
Name
DOB
City, State, Zip
Email Address
example@example.com
Referred by
Marital Status

SingleMarriedDivorcedCohabitating
Spouse/Significant other
Anniversary
Children (Name/Age)
What is your primary cancer diagnosis? (type & stage)
What is your secondary cancer diagnosis? (type & stage)
Are you currently receiving treatment?

YesNo
Oncologist
Are you currently seeing more than one medical/health specialist?

YesNo
Have you received genetic testing? If yes, what were the results?
Do you need transportation to/from treatment?

YesNo
Do you have health insurance?

YesNoOther
OCCUPATIONAL INFORMATION:
Are you currently employed?

YesNo
If yes, will you work during treatment?
If yes, who is your currently employer/position?
RELIGIOUS/SPIRITUAL INFORMATION:
Do you consider yourself religious

YesNo
Do you follow a specific faith/religion? If yes, which religion?
Do you consider yourself spiritual?

YesNo
Are you open to prayer?

YesNo
Prayer request
Inadequate or lack of insurance coverage?

Difficulty paying bills?

Need for financial assistance from Medicaid/Medicare?

Confusing financial paperwork?

Need for prescription assistance?

Need for medical equipment/supplies Other?

Physical Needs (Child/elder care Housing/housing problems Food, clothing, other physical needs Prostheses, wigs, etc.)

Vocational support (job skills, employment skills)

Extended care needs: home care, hospice, long-term care [ ] Other:
Other
Care Package
Floral Arrangement
Should be Empty:

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