Guest Intake Form 2025

WeSPARK Cancer Support Center
Please complete the following sections:
First Name*
Last Name*
Email*
example@example.com
Phone #*
Format: (000) 000-0000.
Street Address*
City*
State*
State Initials Ex: CA
Zip code*
Age
Birth Date*

MonthDayYear
Date
Gender*

MaleFemaleOther
Emergency Contact Name*
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to you
Marital Status*

UnmarriedMarriedLife PartnerDivorcedWidowed
Number in household*
Name of Spouse/ Partner (if applicable)
Name and Ages of Children (if applicable)
Indicate your PRIMARY Reason for joining: (Can select multiple)*

I have CancerI have a reoccurrenceI HAD CancerI am a CaregiverI have lost a loved one to Cancer
Type(s) of cancer*
Stage
Date of Diagnosis

MonthDayYear
Date
Date of Recurrence (if applicable)

MonthDayYear
Date
What statement describe you best:*

I'm in ACTIVE TreatmentI'm in MAINTETANCE Treatment or Remission TreatmentI'm in ONGOING Treatment (doesnt not end)I'm POST Treatment (Done!)
What is your treatment type?*

ChemotherapyChemo PillSurgeryRadiationPending/ unsureOther
Date of first treatment*

MonthDayYear
Date of first treatment
Date of final treatment

MonthDayYear
Date
Oncologist (if applicable)*
Radiologist
Facility/Hospital*
Are you experiencing side effects?

YesNo
Describe your side effects:
Their name*
Relation to you*
Type(s) of cancer*
Stage
Date of Diagnosis or Recurrence*

MonthDayYear
Date
Are they...*

In ACTIVE TreatmentIn ONGOING TreatmentIn POST Treatment
Oncologist
FacilityHospital
Name of loved one*
Relationship to you*
Date of loss*

MonthDayYear
Date
Type(s) of Cancer*
What activities groups or services are you involved in ie classes sports community service support groups etc
Are you currently under the care of a mental health provider?

YesNo
IF Yes, who?
Do you struggle with Depression?*

YesNo
Do you struggle with Suicidal Thoughts?*

YesNo
Are you taking medication for mental health?

YesNo
If so which?
Do you have any other major medical issues?
How/Where did you hear about WeSPARK*
Help us keep WeSPARK free of charge by providing the following information:
PLEASE NOTE: YOUR NAME IS KEPT CONFIDENTIAL AND THE INFORMATION YOU PROVIDE WILL HAVE NO EFFECT ON YOUR ELIGIBILITY FOR SERVICES AT WeSPARK.
Your occupation*
Employer (if applicable)*
What form(s) of transportation will you use to get to WeSPARK? (Select all that apply)*

My own VehicleRide from Family/ FriendAccess/ City RideTaxi/ UberBusWalkOther
Please check one box that best describes your current household yearly income (confidential - Grant purposes)*

$0-$15K$16k-$30K$31K-$45K$46K-$60k$61K-$75K$76K-$90KOver $91k
What is your ethnicity/race?*

African AmericanNative American/ Alaskan NativeHipanic/ LatinoAsian PacificCaucasianMiddle Eastern/ PersianOther
What is your current healthcare coverage*

Private Insurance / EmployerMedicareMedi-CalCSMP/ MISPNoneOther
GUEST ELIGIBILITY POLICY
WeSPARK enhances the quality of life for cancer patients, survivors, and their loved ones. WeSPARK provides free programs and services, which alleviate the physical and emotional side effects of a cancer diagnosis.

Below are the eligibility requirements for our free Programming.

Eligible Guests:
- Cancer Patient: is defined as a person who is diagnosed with cancer within the past 5 years, and/or is in treatment and/or is diagnosed with recurrence or metastasis - Eligible for services up to 5 years from date of completed intake.
- Caregivers: is defined as a family member or loved one who is currently caring for a cancer patient. - Eligible for services up to 5 years from date of completed intake.
- Friends: is defined as a close friend of a cancer patient whose cancer diagnosis/treatment is causing the friend significant emotional difficulty. - Eligible for services up to 2 years from date of completed intake.
- Grief/Bereavement: is defined as a person who is experiencing significant loss due to the death of a loved one from cancer within the last 2 years. - Eligible for services up to 1-2 years from date of completed intake.
- WeSPARK Ambassadors: is defined as a current guest who is 5+ years post cancer/treatment. - *Eligible for Virtual/Online movement & mindful classes, WeSPARK Annual Holiday Party, Special Community Workshop/Speakers Series and one (1) distinct in-person class per month.
(Distinct in-person class is defined as: any movement, stretch, yoga, or dance class)

*WeSPARK Ambassadors may not be eligible for certain "Limited Space" Special Programs or Classes,

Please check with Guest Services for eligibility.

Guests who have completed an intake but have not attended WeSPARK for a period of 12 months will be required to complete a follow up meeting with a Facilitator to update our records and your eligibility.

ALL guests will be required to have a follow up meeting upon completion of their Services Eligibility period (see above for years of eligibility)

Eligibility for Individual Sessions/Appointments:

(Appointment Eligibility does NOT guarantee appointment availabillity due to scheduling restricitons)
- Cancer Patients in active treatment, hospice, or metastasis (4 appointments per month)
- Post-treatment cancer patients with less than 6 months since treatment (3 appointments per month)
- Post-treatment cancer patients with 6-24 months since treatment (2 appointments per month)
- Post-treatment cancer patients with 2-5 years since treatment (1-2 appointments per month, determined on a case-by-case basis)
- Patients in ongoing maintenance treatment (1 appointment per month)
- Caregivers of cancer patients who are in active treatment or hospice (2 appointments per month)
- Caregivers of cancer patients not in active treatment (1 appointment per month)
- Recently bereft guest - in the first 12 months (2 appointments per month)
- Bereft guests - 12-24 months from loss (1 appointment per month)
ALL Guests are limited to a maximum of one (1) individual appointment per week and one (1) individual modality per month.

Limiting guests to one (1) individual session per week allows time to absorb the benefits of the session and one (1) modality per month allows time to explore the various modalities we offer.

"No Show" appointments:

If a guest has 3 "no shows" or cancellations less than 24 hours before their appointment, scheduling may be suspended.

WeSPARK reserves the right to refuse services to anyone at any time that is deemed inappropriate for our programs or who will not benefit from the programs and services WeSPARK provides.

Guest Eligibility Policy and terms may change at any time with or without notice.
Guest Code of Conduct
WeSPARK is a safe and supportive environment where one can share their experience, strength, and hope. We are here to support, assist and guide one another. Because we are unique individuals, we are in different places emotionally, physically and within our own recovery. As guests of WeSPARK we want to avoid comparing and judging each other. Experiences and opinions shared here are your own and are not necessarily those of WeSPARK.

We ask that each guest follow these standards while participating in WeSPARK programming:
- Maintain confidentiality of any personal information that is shared with you by another guest or staff member and understand that your information will be held as confidential.
- Do not judge the feelings and experience of others and understand that your experiences and feelings will not be judged.
- Your experiences and pain will not be compared or minimized.
- You have the right to not share your feelings and experiences.
- You have the right not to be criticized or blamed.
- Verbal attacks will never be tolerated.
- Recognize that each guest may be at a different stage of the healing process. *Respect will be maintained for all races, religions, ethnic groups, sexual orientations, disabilities, and socioeconomic status.
- Out of respect for practitioners and other guests, please arrive on time or early for classes or sessions. Please note: We allow a 5-minute grace period after start time for Yoga and Guided Imagery. After this time, guests will not be allowed to join the class. No exceptions.
Statement Of Understanding

WeSPARK facilitators do not provide or give medical, legal, or intensive/extensive psychotherapeutic advice or treatment. In some circumstances, you may be encouraged to seek advice or treatment from medical doctors, attorneys, psychotherapists, or other licensed healthcare professionals for those types of services.

Under California law, there are certain situations under which we are legally bound to break confidentiality. We are required to break confidentiality when a person may be dangerous to himself/herself or to others, or if someone is involved in child or elder/dependent adult abuse. In these situations, we would need to notify the police, and/or other reporting agencies, or individuals to whom we would release only that information pertinent to the reportable

WeSPARK is not responsible for the views, opinions, and/or services any guest receives from a WeSPARK referral and/or facilitators. Outside individuals and/or groups that provide any type of service here are Independent Contractors and are not employed by WeSPARK. Furthermore, WeSPARK does not necessarily share the views of any third parties or otherwise warrant, endorse, support, or verify the reliability of the services they provide.
- WeSPARK reserves the right to refuse service to anyone.
- WeSPARK prohibits the use of alcohol or illegal drugs while using our services.
- WeSPARK bans the possession of weapons on the premises at all times.
- WeSPARK staff and facilitators are prohibited from providing transportation to guests.
Responsibility for Physical Activities Agreement

WeSPARK offers various movement classes to lighten and enhance your journey in recovery.

There are risks associated with any physical activity. Therefore, prior to engaging in any movement class / physical activity at WeSPARK, please check with your physician to make sure that the activity is appropriate and safe for your condition.

WeSPARK will not assume responsibility of any kind for any type of injury that may result from any activity voluntarily engaged in at WeSPARK.

WeSPARK Guest Service Agreement

I have read, fully understand, and voluntarily agree with all the information in the WeSPARK Guest Intake Packet, which includes the Guest Form, Guest Eligibility Policy, Guest Code of Conduct Agreement, and the Responsibility for Physical Activities Agreement.
Name*

First Name Guest or Parent/GuardianLast Name
Date*

MonthDayYear
Date
Signature*
Should be Empty:

WeSPARK Cancer Support Center

PLEASE NOTE: YOUR NAME IS KEPT CONFIDENTIAL AND THE INFORMATION YOU PROVIDE WILL HAVE NO EFFECT ON YOUR ELIGIBILITY FOR SERVICES AT WeSPARK.

GUEST ELIGIBILITY POLICY

Guest Code of Conduct