Cancer Care Services Intake Form
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  • Cancer Care Services Intake Form

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    Thank you for your interest in Cancer Care Services! This form gathers all the information we need to give you help.

     

    If you need help filling out this form or need to give us documents in-person, please call us at 817-921-0653 to set up an appointment. 

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    You can save this form if you need more time to work on it.

    _____________________________________________________________________________ 

  • Do you live in Tarrant County, Texas?

  • Since you do not live in Tarrant County, we cannot give you financial services, but we can still help you! You can keep filling out this form, but you can only get non-financial services.

    You can also fill out our shorter "Contact Us" form. Tell us what kind of help you are looking for and one of our social workers will reach out to discuss resources you might be eligible for.

    Link to Contact Us Form: https://form.jotform.com/212014237264041 

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Can we send you emails?
  • Do you have someone you want us to reach out to if we cannot get in touch with you?*
  • Format: (000) 000-0000.

  • We ask for demographic information because we want to make sure that we are helping everyone. The organizations that fund us also want us to have this information. If you are uncomfortable answering a question, select "Prefer not to Say" or "Decline to Answer". 

    Demographic information is not used to make eligibility determinations.

  • Hispanic, Latino/a, or Spanish Origin?*

  • Cancer Care Services defines homelessness as not having a permanent place you can call your own to sleep. This includes staying with friends for a short time or living in a car/shelter.

  • Eligibility Information

  • What day did you find out you had cancer (your diagnosis date)? If you do not know the exact date, select the 1st day of the month you were diagnosed.*
     - -
  • Have you had cancer before?
  • Do you have another kind of cancer right now?
  • Are you receiving treatment right now?*
  • Are you receiving treatment in the next two weeks or did you finish it in the last 6 months?*
  • (Select all that apply) What kind of treatment(s) have you received or will you receive?*

  • Income and Insurance Information

    • Household Income information must be provided to Cancer Care Services to be considered for financial assistance.

    • List the Names and Ages of all people living in the home.
      The only exception are 'rented rooms' (e.g. hotels, boarding homes).

    • Please tell us the gross monthly income and source of income for every person earning income in the household.

    SEE BELOW FOR EXAMPLES

    Robert Paschal, Age 59, $3250 from Work

    Julius Hemphill, Age 26, $1236 from Long-Term Disability

    Reby Cary, Age 17, No Income

     

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  • The applicant/patient receives   *   per month from   *   

  • Does anyone else live in the household right now?*

  • *   receives   *   per month from   *   

  •    receives      per month from      

  •    receives      per month from      

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  • Do you have health insurance or COBRA?*

  • Financial Services Information

  • Attention: Completing this section does not guarantee financial assistance from Cancer Care Services. You must provide us all the information and documents we are asking for before assistance is given. You can submit this application without all the documents if you need time to gather them.

  • Select the Financial Services you want to learn about/apply for (Please note that Transportation will be on the next page):*

  • Medication Assistance

    • We can pay for up to $150 per month, for 6 months, of your cancer-related medications. The $150 does not rollover from month to month.

    • Coverage for medications that are not cancer-related are reviewed on a case-by-case basis.

    • Some pharmacies will not work with us to pay for your medicine. You might have to switch pharmacies to get help or give us full receipts of your medications so that we can pay you back.
  • Do you want to receive medication assistance or reimbursement?*

  • Health Insurance Premium/COBRA Assistance

    • We can pay for up to $1,000 or 6 months of your Health Insurance Premiums or COBRA premiums (HIP/COBRA), whichever comes first.

    • The person with cancer (applicant) does not have to be the person who pays for the HIP/COBRA. We will help the person who pays for the applicant's premiums.

    Cancer Care Services only covers the cost of health insurance. Vision, Dental, FMLA, STD/LTD, Life, Cost-Share, and Supplemental policies are not covered by this service. Medicare, Medicaid, and Tricare premiums are not covered by this service.

     

     

  • Do you want to get help with your Health Insurance Premiums or COBRA payments?*
  • How do you pay for your Health Insurance Premiums or COBRA?
  • When is the premium/payment due?
    • Please tell us how we would make a payment for you.

    • Tell us who a payment should be made to. If you don't know who a payment should be addressed to, the person at your job that tells you about health insurance (benefits representative) may be able to tell you.

     

     

  • How should we pay for your HIP/COBRA payments?*
  • Format: (000) 000-0000.

  • Documents Required 

     

    • If you do not have documents yet, GO TO THE NEXT SECTION.
    • You must give us documents that show how much you owe/pay for HIP/COBRA.
    • The documents must clearly show your (or the person who pays for your insurance) name and where/how to make a payment.
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  • Nutrition

  • We can give nutritional supplements (ex. Boost Plus, Isosource 1.5) for free if you meet any of the following:

    • Have a Head and Neck Cancer*

    • Have an Esophageal/GE junction Cancer

    • And/Or Have a Feeding Tube (j-tube, g-tube, etc.)

    You must tell us your dietitian's contact information (name, phone number or email). If you are approved for services, your social worker will reach out to the dietitian.

    *Head and neck cancers are reviewed on a case-by-case basis by Director of Programs.

  • Do you have a Head and Neck Cancer, Esophageal/GE Junction Cancer, and/or a feeding tube?

  • We are sorry, you are not able to receive nutrition help from us.

    Abbott Nutrition might be able to help you with getting some nutrition. Visit this link: https://www.pathwayreimbursement.com/patient.html or call 855-217-0698 to see what nutrition they can help with. If you have been prescribed a different kind of nutrition, ask your dietitian if they can write a new prescription for one that Abbott Nutrition does help with.

     

    SNAP (food stamps, Supplemental Nutrition Assistance Program) also might be able to help you cover the cost. Call 211 and ask for help filling out a SNAP form. Or visit: https://www.yourtexasbenefits.com/Learn/Home

  • Transportation Assistance

  • We can help you get to some of your treament appointments.

    Please note:

    • There is a limit for transportation assistance, we may not be able to help you with every appointment you have.

    • You must give us your full treatment schedule. If you do not have one, talk to the person who checks you in, your social worker, or your nurse at your treatment location. Ask them to print or email you a copy of your schedule.

    • Appointments for other healthcare visits are reviewed on a case-by-case basis.

    • Appointments for non-cancer related needs are not covered.

    _____________________________________________________________________________

  • For transportation assistance...*
  • Do you have a treatment schedule you can upload right now? NOTE: Until you give us a treatment schedule, we cannot help you with transportation.*
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  • Emergency Funds/Direct Financial Help

  •  

    As of September 2024, our Emergency Funds are CLOSED. Please note that availability is subject to funding and can be closed at any time. 

    Cancer Care Services can cover:

    • Household bills (electricity, water, phone, internet)
    • Car Loan/Note, Car Insurance, Car Repair
    • Property taxes (Late Only)
    • Other types of bills might be covered on a case-by-case basis.

    Cancer Care Services cannot cover:

    • Rent or mortgage
    • Cable / streaming services
    • Medical debt, copays, or procedures
    • Credit card debt
    • Car registration fees
    • NOTE: this is not a total list of bills not covered by Cancer Care Services.

    Bills must:

    • Clearly show your (or someone in your household's) name. 
    • Clearly show where the bill's from, amount due, and where/how to make a payment.

    Emergency Funds are ONE-TIME ONLY. EMERGENCY FUNDS ARE CURRENTLY CLOSED UNTIL FURTHER NOTICE.

    _____________________________________________________________________________

     

  • Are you interested in receiving direct financial help?
  • Please read the statements below and click if you agree to the statements. If you do not agree to all of the statements, you will not be able to receive direct financial help.
  • I need help with these household bills because (check all that apply):
  • Do you need help with groceries?

  • Tarrant Area Food Bank has a list of food pantries in North Texas. Visit: https://tafb.org/find-food/ or call 817-857-7100.

    At times, Cancer Care Services may be able to provide grocery (ex. Walmart) cards.

  • If you are approved for services and we have some to give, would you want grocery cards?

  • I am asking for help with * for   *   from * . The person who is responsible for the bill's phone number is      *   

  • I am asking for help with for      from . The person who is responsible for the bill's phone number is         

  • I am asking for help with for      from . The person who is responsible for the bill's phone number is         

  • I am asking for help with for      from . The phone number on the account is      

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  • You cannot give us the exact same bills (ex. your May electric bill) that you gave to other agencies or non-profits. However, you can give us other bills for different months (ex. your June electric bill).

  • For the bills you submitted, have you received assistance from another agency using American Rescue Plan Act (ARPA) Funding? (KEEP HIDDEN)*
  • If the same bills you give to us are paid by another agency using ARPA funding, you may not be able to get help from us again. Do you understand? (KEEP HIDDEN)

  • If you have a caregiver you would prefer us to contact about your financial assistance, or the applicant is a minor, please provide the caregiver/guardian's information below.

  • Please continue to next page.

  • Connecting Services

  • Cancer Care Services is proud to provide other services such as social events, help understanding your health insurance, and spiritual support!

  • Please select the service(s) above that you are interested in learning more about:*

  • Counseling

  • Cancer Care Services offers free-of-charge individual counseling for ages 5 and up. Counseling is available to Tarrant County residents only. Virtual counseling is offered!

    Please give us the best phone number and email to contact you, your caregiver, or a parent/guardian (if not provided above).

    Please write days and times that would be best for us to contact you to do a separate counseling application.

     

    Other resources that may be helpful for you:

    • Cancer Support Community has many kinds of support groups and activities like yoga, meditation, and cooking! Find your local chapter here: https://www.cancersupportcommunity.org/find-location-near-you 
    • Imerman Angels is a mentorship program for both people with cancer and their caregivers. You will be matched with an "Angel", someone who has been through similar experiences.
      You can find out more here: https://imermanangels.org/ 

     

  • Format: (000) 000-0000.

  • CONNECT

  • Our CONNECT program brings you together with other people who have been impacted by cancer through fun events like movie nights, holiday events, and camps/retreats. The CONNECT program is open to anyone, regardless of treatment status, income, or where they live.

    The email you gave at the beginning of this application will be used to send our monthly list of events. Please reach out to us at 817-921-0653 if you do not have an email or if you have questions about events!

    If you would prefer the list of events to go to a different email, you can use the box below to tell us which email you want to use.

  • Advanced Care Planning

  • Thank you for your interest in Advanced Care Planning (ACP)! These conversations are important for everyone, because it gives you a voice if you are not able to speak for yourself.

    Please write days/times you could be reached out to!

    I can assist with:

    • Completing Do-Not-Resuscitates, Medical Power of Attorney, Durable (Financial) Power of Attorney, and Directive to Physicians.
    • Advice on the hospice process.
    • Consulting on final arrangements including burial, organ/body donation, and cremation.

     

    If you need assistance with a Last Will and Testament, you can consult with an attorney or visit FreeWill for help: https://www.freewill.com/

     

  • Spiritual Support Program

  • The Spiritual Support Program offers individualized spiritual navigation and group events designed to nurture emotional and spiritual well-being for those impacted by cancer. Rooted in compassion and inclusion, this program is not tied to any specific belief system but instead provides a safe space for individuals to explore their sense of meaning, hope, and healing. Whether through one-on-one guidance or therapeutic group gatherings, our goal is to support each person's unique journey toward inner peace and resilience.

  • Financial Navigation

  • Many people feel confused about insurance terms, their bills, and how to navigate our healthcare system. Financial Navigators at Cancer Care Services can provide you with information you need to help you through this journey.

    Thank you for your interest in our financial navigation program! Please give us the contact information for the person who wants to receive financial navigation and days/times they can be contacted.

  • Format: (000) 000-0000.

  • Distress Tool

  • If you have time, please fill out the Distress Tool. If you are short on time, select "I will complete when you call for an intake".

  • This is a tool we use to help understand what parts of cancer are causing you the most distress/problems right now. We can provide you with resources based on your answers. After the Distress Tool, you will have a section where you can tell us more about the needs you have right now.

     

    The questions start with "Today, how concerned are you about..." The scale is 0-4, 4 being highest.

  • Today, how concerned are you about Communicating with your doctor*
  • Changes or disruptions in work, school, or home life*
  • Feeling sad or depressed*
  • Pain and/or Physical Discomfort*
  • Body image and feelings about how you look*
  • Feeling nervous or afraid*
  • Worrying about the future and what lies ahead*
  • Making a treatment decision*
  • Intimacy, sexual function, and/or fertility*
  • Feeling lonely or isolated*
  • Health insurance or money worries*
  • Problems in your relationship with your spouse/partner*
  • Feeling too tired to do the things you need or want to do*
  • Exercising and being physically active*
  • Thinking clearly (e.g. "chemo brain", "brain fog")*
  • Tobacco or substance use*

  • Here is a quick link to all of our events coming up!: https://cancercareservices.org/events/ 
    NOTE: Certain events may require you to RSVP. The staff at these events cannot help you get financial services or answer questions about your application status.

  • Looking for other kinds of help too? Our website has resources for other agencies/non-profits that you can look through today! Here is the link: https://cancercareservices.org/resources/ 

     

    Want to stay in touch with us and learn about what is new? You can sign up for our newsletter here: https://cancercareservices.us18.list-manage.com/subscribe?u=8ed7d64ddd31b3535f5159e49&id=8871a869c1 

  • Please save our phone number, 817-921-0653, into your phone/contact list so that our calls do not show up as spam. If you do not answer our contact attempts your application will be put on a waitlist.

     

    Click Submit if you are ready to send us your application. Click Save if you need to come back to the application later.

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