Canc3rPress Oncology Clinician Intake Form
Share your professional background, referral interests, and care considerations—without including any patient-identifiable information or PHI.
Canc3rPress Oncology Clinician Participant Intake Form
Full Name
*
First Name
Last Name
Credentials / Licensure
*
Professional Role
*
Organization / Practice Name
*
Specialty / Clinical Focus
*
Populations Served
*
Work Email
*
example@example.com
Work Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
State
*
Preferred Contact Method
*
Email
Phone
Why do you want to participate in Canc3rPress?
*
What personal or professional wellness goals would you like to work toward?
*
What wellness areas would be most helpful for you right now?
*
Fitness and movement
Emotional well-being
Stress management
Spiritual wellness / Christian encouragement
Education and learning
Community and peer support
Professional renewal
Rest and recovery
What are your current stress, fatigue, work-life balance, or burnout-prevention needs?
*
What physical activity and wellness habits do you currently have?
*
What barriers make it harder for you to focus on your own wellness right now?
*
What preferred program format and scheduling would work best for you?
*
How ready are you to participate consistently?
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Very ready
Somewhat ready
Not sure yet
What accessibility or accommodation needs should we know about?
What would meaningful progress look like for you over the next 3–6 months?
*
How important is faith or spiritual support to you personally?
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Very important
Somewhat important
Not important
Are you comfortable receiving Christian faith-based encouragement?
*
Yes
No
Maybe
Optional prayer requests or spiritual goals
Canc3rPress wellness programming does not replace medical or mental-health care, and please do not include any patient-identifiable information or PHI.
Do you consent to be contacted about participation and next steps?
*
Yes
No
Professional Information
Full Name
*
First Name
Middle Name
Last Name
Professional Title / Role
*
Credentials / Licensure
Organization / Practice Name
*
Department / Program
Work Email
*
example@example.com
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
Preferred Contact Method
Email
Phone
Either
Professional Background
Role
*
Medical oncologist
Radiation oncologist
Surgical oncologist
Oncology nurse/NP
Physician assistant
Physical therapist
Occupational therapist
Exercise physiologist
Rehabilitation professional
Registered dietitian
Social worker
Psychologist/counselor
Chaplain/spiritual care professional
Patient navigator
Survivorship professional
Administrator/program leader
Primary care clinician
Other
Specialty / Clinical focus
Years working with oncology populations
Populations served
Adult survivors
Adolescent/young adult
Older adults
Caregivers/families
Active treatment
Post-treatment survivorship
Metastatic/advanced cancer
Bereavement
Other
Survivorship & Caregiver Needs
Unmet needs you commonly observe
*
Safe physical activity/exercise guidance
Rebuilding strength/endurance
Fatigue management
Mobility/balance/function
Healthy lifestyle education
Survivorship transition
Stress/emotional wellness
Caregiver wellness
Peer/community support
Spiritual wellness
Grief/bereavement
Access/resource barriers
Social isolation
Education/navigation
Other
Optional: Describe gaps you see in survivorship or caregiver support in your community
Familiarity & Referral Interest
How familiar are you with Canc3rPress?
*
New to it
Somewhat familiar
Very familiar
How interested are you in referring cancer survivors?
*
Not interested
Somewhat interested
Very interested
How interested are you in referring caregivers?
*
Not interested
Somewhat interested
Very interested
Which services would you feel comfortable discussing or referring to?
*
Survivor fitness/wellness
Caregiver wellness
Survivorship support
Christian spiritual wellness/encouragement
Educational resources/workshops
Peer/community support
Stress management/mind-body wellness
Community events
Other
What information or evidence would you need before making referrals?
What referral process would you prefer?
*
Secure online referral if available
Provide information to patient or caregiver for self-referral
Direct professional contact
Other
Safety & Clinical Coordination
What information would increase your confidence in a cancer wellness referral program?
*
Participant screening procedures
Medical-clearance process
Staff qualifications
Exercise safety protocols
Scope-of-practice boundaries
Emergency procedures
Communication back to referring clinicians
Privacy and data practices
Outcomes and reporting
Other
Are there any referral, vendor, partnership, privacy, or compliance requirements we should be aware of?
Referral agreement required
Vendor registration required
Partnership agreement required
Privacy review required
Compliance review required
Insurance/coverage verification required
Other
Optional recommendations for safe coordination of care
Faith & Spiritual Wellness
Briefly explain that Canc3rPress may incorporate Christian faith-based encouragement and spiritual wellness resources while respecting participant choice.
How comfortable are you referring individuals to a program that clearly offers optional Christian faith-based support?
*
Comfortable
Comfortable if clearly optional
Need more information
Not comfortable
Prefer not to answer
Is spiritual care or faith-based support currently available in your setting?
*
Yes
No
Unsure
Prefer not to answer
Education & Resources
Topics of interest
*
Exercise in cancer survivorship
Caregiver wellness
Cancer-related fatigue and wellness strategies
Behavior change and healthy lifestyle
Spiritual wellness
Survivorship resources
Community-based oncology wellness
Clinician-to-community referral pathways
Other
Preferred resource format
*
One-page referral guide
Patient handout
Digital toolkit
Webinar
In-service presentation
Community event
Professional meeting
Other
Communication & Follow-Up
Preferred contact method
*
Email
Phone
Text message
Organization main office
Other
Best days and times to reach you
Is there anything else you would like Canc3rPress to know about your clinical work, the needs of the populations you serve, or how we can best support appropriate referrals?
Interest in a follow-up conversation
*
Yes
Maybe later
No at this time
Professional Acknowledgments & Consent
Acknowledgments and consents
*
I confirm that no patient-identifiable information or protected health information has been intentionally included
I understand that Canc3rPress provides supportive wellness and community programming and does not replace medical diagnosis, treatment, rehabilitation, mental health treatment, or emergency care
I consent to be contacted about referral opportunities and next steps
Optional communications
Professional updates
Educational resources
Events
Canc3rPress program news
Acknowledgment signature
*
Date of acknowledgment
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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