Steady Hearts – Client Intake Form
Please complete this information prior to starting advocacy support.
Client Full Name:
Date of Birth:
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Month
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Day
Year
Date
Phone Number:
Email Address:
example@example.com
Preferred Contact Method:
Emergency Contact:
Primary Diagnosis (if known):
Current Treatment Status:
Oncology Team / Facility:
Primary Concerns or Goals:
Additional Notes:
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Authorization to Share and Discuss Health Information
This authorization allows Steady Hearts Advocacy, a non clinical advocate, to receive and discuss medical information for the purpose of care navigation, scheduling help, treatment research, and communication support. This is not a HIPAA medical release but a permission agreement between the client and advocate.
Client Name:
Date of Birth:
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Month
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Day
Year
Date
Individuals or Providers Allowed to Share Information:
Types of Information Allowed (labs, imaging, notes):
Purpose of Sharing: Care navigation and advocacy
Expiration Date of Authorization:
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Month
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Day
Year
Date
Client Signature:
Date:
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Month
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Day
Year
Date
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Scope of Services Agreement
This agreement explains what Steady Hearts Advocacy provides and clarifies expectations.
Steady Hearts provides plain language explanation of labs and imaging, treatment and clinical trial research, appointment preparation, care coordination, emotional support, and communication guidance.
Steady Hearts does not diagnose, recommend medical treatment, prescribe medication, or provide emergency care.
Billing: Services are billed according to chosen hourly or package rates.
Cancellation: A minimum of 12 hours notice is requested for changes or cancellations.
By signing below, the client acknowledges and agrees to these terms.
Client Name:
Client Signature:
Date:
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