Canc3rPress Caregiver Intake Form
Share your caregiving experience and your own wellness needs so Canc3rPress can support you appropriately.
About You
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Age Range
Please Select
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Phone
Email
Text Message
Either Phone or Email
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
Emergency Contact Name
Emergency Contact Relationship
Your Caregiving Experience
Relationship to the person affected by cancer
*
Spouse/Partner
Parent
Child
Sibling
Friend
Other
Current caregiving status
*
Currently providing care
Providing occasional/supportive care
Former caregiver
Bereaved caregiver
Prefer not to answer
Other
Approximate length of caregiving experience
*
Please Select
Less than 6 months
6–12 months
1–2 years
3–5 years
More than 5 years
Prefer not to answer
Approximate hours per week spent caregiving
Primary caregiving role
*
Primary caregiver
Shared caregiving role
Supplemental caregiver
Prefer not to answer
Broad phase of your loved one's cancer journey
*
Newly diagnosed
Active treatment
Post-treatment/Recovery
Long-term survivorship
Recurrence/Metastatic/Advanced cancer
End-of-life/Hospice
Bereavement
Prefer not to answer
Other
What would you like us to understand about your caregiving experience?
Caregiver Well-Being
Overall well-being right now
*
Very low
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very low, 10 is Excellent
Energy / fatigue level
*
Very fatigued
1
2
3
4
5
6
7
8
9
Very energetic
10
1 is Very fatigued, 10 is Very energetic
Current stress level
*
No stress
1
2
3
4
5
6
7
8
9
Extremely stressed
10
1 is No stress, 10 is Extremely stressed
Quality of sleep
*
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Ability to make time for your own health
*
Very difficult
1
2
3
4
5
6
7
8
9
Very easy
10
1 is Very difficult, 10 is Very easy
Sense of social support
*
Very little support
1
2
3
4
5
6
7
8
9
Strong support
10
1 is Very little support, 10 is Strong support
Emotional well-being
*
Very low
1
2
3
4
5
6
7
8
9
Very strong
10
1 is Very low, 10 is Very strong
Which challenges are you currently experiencing?
Fatigue / exhaustion
Stress / anxiety
Sadness / grief
Sleep difficulties
Physical strain from caregiving
Lack of exercise / movement
Difficulty maintaining healthy routines
Isolation / loneliness
Difficulty asking for help
Balancing work / family / caregiving
Financial strain
Spiritual struggles / questions
Loss of personal time
Uncertainty about the future
Prefer not to answer
Other
Physical limitations or accommodations for wellness participation
Current Wellness & Activity
How would you describe your current activity level?
*
Very active
Somewhat active
Lightly active
Mostly inactive
Unsure
What types of exercise or movement do you currently do?
Walking
Stretching or yoga
Strength training
Cardio or aerobic exercise
Dance
Household or caregiving-related movement
Physical therapy exercises
Other
How many days per week do you typically do intentional movement or exercise?
*
What are the biggest barriers to caring for your own wellness?
Time
Fatigue
Motivation
Cost
Transportation
Lack of support or respite
Physical limitations
Stress or emotional demands
Uncertainty where to start
Other
Caregiver Wellness Goals
What are your wellness goals?
*
Increase energy
Rebuild/maintain strength
Improve mobility/flexibility
Improve endurance
Establish a consistent exercise routine
Manage stress
Improve sleep habits
Make time for self-care
Improve emotional well-being
Strengthen faith/spiritual wellness
Reduce isolation/connect with others
Learn healthy lifestyle strategies
Improve confidence
Find balance between caregiving and personal needs
Navigate grief/loss
Other
What would meaningful progress look like for you over the next 3–6 months?
Please choose your top three priorities from the list above.
Spiritual Wellness
How important is spiritual or faith-based support in your caregiving or wellness journey?
*
Very important
Somewhat important
Not important
Unsure
Prefer not to answer
Would you be comfortable receiving Christian faith-based encouragement or resources from Canc3rPress?
*
Yes
Sometimes, depending on the context
No
Prefer not to answer
Are you involved in a church or faith community? (Optional)
Optional: Are there spiritual needs, prayer requests, questions, grief concerns, or faith-related goals you would like to share?
Support Needs
Which types of support would be most helpful to you?
*
Caregiver fitness/wellness
Stress management
Self-care strategies
Caregiver peer/community support
Christian encouragement/spiritual wellness
Grief/bereavement support
Education/resources
Healthy lifestyle education
Respite/resource navigation
Survivorship-family support
Community events
Other
Do you currently have a support system? Who is part of it?
*
Family
Friends
Church/faith community
Healthcare/social-work team
Support group
Community organization
None currently
Other
Canc3rPress Program Interests
Which program topics are you interested in?
*
Caregiver wellness/fitness
Caregiver support/community
Spiritual wellness/Christian encouragement
Educational workshops/resources
Stress management/mind-body wellness
Grief/bereavement resources
Healthy lifestyle programs
Community events
Family/survivor-caregiver programming
Other
Preferred participation format
*
In-person
Virtual
Hybrid
No preference
Preferred participation style
*
Individual
Small group
Larger group/community
No preference
Preferred scheduling times
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
Flexible / no preference
Other
Readiness
How ready are you to make your own wellness a priority?
*
Not ready
1
2
3
4
5
6
7
8
9
Very ready
10
1 is Not ready, 10 is Very ready
What might make it easier for you to participate in a wellness or support program?
If enrolled, are you able to participate consistently?
*
Yes
Probably
Unsure
Not at this time
Accessibility & Practical Needs
Accommodations or accessibility needs
Wheelchair access
Elevator access
Accessible restroom
Large-print materials
Audio support
Sign language interpretation
Captioning
Quiet space
Flexible pacing
Other
Transportation concerns for in-person programs
No concerns
Limited access to transportation
Need help arranging transportation
Cost is a barrier
Schedule conflicts
Other
Technology or internet concerns for virtual programs
No concerns
Limited internet access
Unstable internet connection
Limited device access
Need help using video meeting tools
Other
Caregiving or respite constraints that may affect participation
No current constraints
Limited free time
Unpredictable caregiving duties
Unable to leave care recipient alone
Need advance notice
Prefer shorter sessions
Other
Preferred communication method
Please Select
Email
Phone call
Text message
Mail
Video call
Other
How You Found Us
How did you hear about us?
*
Oncology or healthcare team
Friend or family
Caregiver organization or support group
Church or faith community
Social media
Internet search
Community event or outreach
Other
Referral source (optional)
Consent & Acknowledgment
Acknowledgment of Information Accuracy
*
I confirm that the information I have provided is accurate and complete to the best of my knowledge.
Program Limitations Acknowledgment
*
I understand that Canc3rPress wellness and support programs do not replace medical care, mental-health treatment, professional counseling, pastoral care, or emergency services.
Consent to Be Contacted for Eligibility and Follow-Up
*
I consent to be contacted regarding eligibility, intake follow-up, and next steps.
Optional Consent to Receive Canc3rPress Updates
I would like to receive Canc3rPress news, educational resources, events, and program updates.
Submit
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