CWC Modality Request Form
Please complete this form with as much detail as possible to be considered for inclusion as a CWC-funded modality. We appreciate your time and thoroughness!
Your Name
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First Name
Last Name
Email
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example@example.com
Are you submitting this request as a practitioner, applicant, or someone else?
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Please Select
CWC-Affiliated Practitioner
Interested CWC-affiliated practitioner
Health Professional
Other
Modality Request
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Please Select
Infrared Sauna
Red Light Therapy
Hyberbaric Oxygen Therapy (HBOT)
Counseling & Mental Health Services
IV Vitamin Therapy
Halotherapy
Traditional Sauna
Homeopathic care
Health Coaching
Other
If you selected Other, please list the modality below:
Request Summary: (Provide a concise summary of the request and why it's being made)
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Does this modality require more than one practitioner to be involved? If so, how many?
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Evidence and Research
Please list and link (or attach below) at least 3 peer-reviewed articles, case studies or credible publications to support inclusion of this modality.
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Article 1
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Article 2
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Article 3
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Research and other scientific articles that support this modality for cancer patients
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Does at least one of these studies include a minimum sample size of 100 study participants?
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Please Select
Yes
No
Does at least one of the studies have a control group?
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Please Select
Yes
No
If you have any anecdotal or experiential support/testimonials for this modality, please share below.
Accessibility & Practicality
Is it currently covered by insurance (that you are aware of?)
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Please Select
Yes
No
A few
What is the length and cost of a typical session?
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Does it require multiple sessions to be effective?
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How can this help a client/caregiver feel better as they go through traditional oncology treatments?
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Safety & Liability
What are the known contraindications, side effects, or risks?
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Is this modality considered safe for patients actively undergoing chemotherapy, radiation, or immunotherapy?
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Would CWC need additional liability coverage for this service?
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Please Select
Yes
No
Unsure at this time
Is there MA Licensure required?
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Please Select
Yes
No
Unsure
What certifications, education, or licenses are needed for someone to offer this modality?
Can you list a few respected professional organizations that endorse it?
Community Need & Fit
Is there a demand or gap for this service among CWC clients or for those going through cancer on Cape Cod and the Islands?
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Are there qualified practitioners currently servicing Cape Cod or the Islands?
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Please Select
Yes
No
Unsure at this time
Does it address an underserved population or modality need?
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Date of Submission
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Month
-
Day
Year
Date
Is there anything else you would like to include?
Submit
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