HOPE Fund for Integrative Therapy
Please use this application to request integrative therapy funding from Shannon's Path. If you have any questions, please reach out to our team at hope@shannonspath.org and allow 72 hours to receive a response from one of Shannon's Path's dedicated team members.
Applicant Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Non-Binary
Prefer not to say
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Email
*
example@example.com
Phone Number
*
Please enter a valid mobile phone number.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred Communication Method
*
Please Select
Email
Phone
Text
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How did you hear about us?
*
Please Select
Personal Contact (Ex: Family Member/Friend)
Medical Professional (Ex: Oncologist, PCP, Office Staff)
Social Worker
Shannon's Path's Website
Social Media
Web Search
Other
Other: Please Describe
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Medical Information
Cancer Diagnosis
*
Please Select
Adrenocortical Carcinoma
Anal Cancer
Appendiceal/Peritoneal Cancer
Biliary Cancer
Bladder Cancer
Blood Disorders
Bone Cancers
BPDCN
Brain Tumors
Breast Cancer
Cervical Cancer
Colon Cancer
Endometrial (Uterine) Cancer
Esophageal Cancer
Gastrointestinal Carcinoid Tumor
Gastrointestinal Stromal Tumor (GIST)
Germ Cell Tumors, Childhood
Gestational Trophoblastic Disease
Histiocytosis
Kidney Cancer
Leukemias
Liver Cancer
Lung Cancers
Lymphomas
Melanoma
Merkel Cell Carcinoma
Mesothelioma
Mouth (Oral Cavity) Cancer
Multiple Myeloma
Myelodysplastic Syndromes (MDS)
Myeloproliferative Neoplasms (MPNs)
Neuroendocrine/Carcinoid Tumors
NUT Carcinoma
Ovarian Cancer
Pancreatic Cancer
Penile Cancer
Prostate Cancer
Rectal Cancer
Salivary Gland Cancer
Skin Cancers (Non-melanoma)
Soft Tissue Sarcomas
Stomach (Gastric) Cancer
Testicular Cancer
Thymoma/Thymic Tumors
Thyroid Cancer
Vaginal Cancer
Vulvar Cancer
Waldenström’s Macroglobulinemia
Other
Year Diagnosed
*
Which of the following best describes your treatment status?
*
In active treatment
Less than one year off treatment
More than one year off treatment
Hospice or end-of-life care
Other
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Medical Care Team
This information will be used by Shannon's Path to contact your provider and verify the suitability of your requested therapy.
Primary Treatment Center
*
Oncologist Name
*
First Name
Last Name
Oncologist Phone Number
*
Please enter a valid phone number.
Oncologist Email
example@example.com
Social Worker Name
First Name
Last Name
Social Worker Phone Number
Please enter a valid phone number.
Social Worker Email
example@example.com
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Have you received a grant from Shannon's Path before?
*
Please Select
Yes
No
Please enter date of previous grant.
-
Month
-
Day
Year
Date
Select desired integrative therapy
*
Please Select
Acupuncture/acupressure
Aromatherapy/essential oils
Art therapy or lessons
Chiropractic care
Craniosacral therapy
Dance
Hippotherapy/therapeutic horseback riding
Fertility preservation
Fitness training
Naturopathic Medicine
Herbal supplements/naturopathy
Martial arts
Massage
Meditation
Music therapy or lessons
Nutritional counseling
Reflexology
Reiki
Swimming/aquatic therapy
TongRen, QiGong
Yoga
Grant amount requested
*
Have you utilized these therapies before?
*
Please Select
Currently receiving
Yes, but not currently
No
Tell us why you would like to receive these services and how you would benefit from them. What impact will these services have on physical/emotional symptoms or side effects?
*
Do you have a preferred provider?
*
Yes
Not yet
Provider Information
Please reach out to your provider to 1) let them know someone from Shannon's Path will be calling to discuss our program and coordinate payment and 2) give them permission to speak to us about your care
Provider Name
*
First Name
Last Name
Provider Phone
*
Please enter a valid phone number.
Provider Email
*
example@example.com
Provider Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Approximate cost of provider per session
*
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Additional Information
Is there any additional information you would like to share?
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Acknowledgment
By checking "I AGREE" below, I signify that I have willingly and voluntarily providing the information contained in this Application, and that I consent and authorize Shannon's Path to collect, store and share such information for all lawful purposes, including (but not limited to)communicating with my health care provider(s) in order to verify the suitability of the therapy for which I am seeking financial support. I understand that I may revoke this authorization at any time except to the extent information has already been released in reliance hereon, and that such revocation must be in writing addressed to Attention: Director, Shannon's Path,9 Hickory Road, Southborough, MA 01772.
Signature
Today's Date
*
-
Month
-
Day
Year
Date
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Release of Liability
As a charitable source of Integrative Therapy funding only, Shannon's Path does not review, approve or warrant the efficacy of any particular therapy nor any therapy provider, and Shannon's Path expressly disclaims any and all such warranties. Applicant hereby releases Shannon's Path, along with its employees, officers, directors, agents, volunteers, consultants, sponsors, successors and assigns, from any and all claims, damages and expenses (including attorney fees) for injury, disability or death, or damage to tangible or intangible property, or any other loss or damage of any nature whatsoever, related to or resulting from participation in any Integrative Therapy for which Applicant seeks charitable funding from Shannon's Path.
Signature
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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