Cancer Care Services Intake Form

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Cancer Care Services Intake Form
Thank you for your interest in Cancer Care Services! This form gathers all the information we need to give you help quickly. We have financial services like helping pay for medications or transportation and non-financial services like social events with other people impacted by cancer.

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. We do not accept walk-in appointments.

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

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Do you live in Tarrant County, Texas?

YesNo
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
Assigned SW/CM
Birth Date*

MonthDayYear
Name of the Patient*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
.
Cell Phone*
Email
Can we send you emails?

YesNo
Do you have someone you want us to reach out to if we cannot get in touch with you?*

YesNo
Caregiver/Other Contact Information*
Name and Phone or Email
Relation to Applicant/Patient*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
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.
Gender*
Sexuality/LGBT Community*
Language Spoken*
Race*
Hispanic, Latino/a, or Spanish Origin?*

YesNo
If you selected "Multiracial", "Other", or "Something Else" to the questions about Gender, Sexuality, Language Spoken, or Ethnicity; please write your answer below.*
Are you a Veteran?*
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.
Are you experiencing homelessness?*
Are you/applicant a single parent household?*

Income and Insurance Information
- Household Income information must be given to get financial services from Cancer Care Services. We may ask you to prove your income at any time.
- 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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Please write the Name and Ages of ALL people in the home. Please write each person's monthly income and source of income, if applicable.*
See examples above.
Number of Adults in Household*
Number of Children Under 18 with Ages*
Ex. 2 kids (11, 9)
The applicant/patient receives Monthly Income in Dollars* per month from *
Does anyone else live in the household right now?*

YesNoN/A
Household Member Name, Relation to Applicant* receives Monthly Income in Dollars* per month from *
Household Member Name, Relation to Applicant receives Monthly Income in Dollars per month from
Household Member Name, Relation to Applicant receives Monthly Income in Dollars per month from
If more than 4 people are living in the household, please write their name, relation to the applicant, monthly income in dollars (if any), and where they get the money from below.
Do you have health insurance or COBRA?*

YesNo
What kind of health insurance, supplemental health care plan, or COBRA plan do you have?*
Are you on JPS Connections? If so, please tell us if you have no health insurance (Connection Primary) or if you do have health insurance (Connection Secondary).*

Connecting Services
Cancer Care Services is proud to provide other services such as social events, help understanding your health insurance, and counseling!
Please select the service(s) above that you are interested in learning more about:*

Events with other people impacted by cancer (CONNECT)Advanced Directives and Care PlanningI am not interested in any at this time
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/
Email
example@example.com
Phone Number
Please enter a valid phone number.
Days and Times We Can Contact You
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.
Email
example@example.com
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.

There is no cost for notarizing the documents or consulting/helping you with your arrangements. Please write days/times you could be reached out to!

I can assist with:
- Completing and notarizing 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.
Please note: I (NOTARY PUBLIC) AM NOT AN ATTORNEY LICENSED TO PRACTICE LAW IN TEXAS AND MAY NOT GIVE LEGAL ADVICE OR ACCEPT FEES FOR LEGAL ADVICE.

Due to liability concerns, I cannot notarize or assist with Last Will and Testaments.

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/
Days/Times You Can Talk about Advanced Care Planning*
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.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Days/Times You can be Contacted