Canc3rPress Spiritual Assessment Form
Share your spiritual well-being, sources of hope, and preferred faith-based support—participation is voluntary.
About You
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Role in Canc3rPress
*
Please Select
Cancer Survivor
Caregiver
Oncology Clinician/Healthcare Professional
Other
Preferred Contact Method
Email
Phone
Text Message
No Preference
Spiritual Background & Identity
Do you identify with a faith or spiritual tradition?
*
Christian
Another faith tradition
Spiritual but not religious
No current faith tradition
Unsure/Questioning
Prefer not to answer
Other
How important is faith or spirituality in your life right now?
*
Very important
Somewhat important
A little important
Not important
Unsure
Prefer not to answer
Do you currently participate in a church or faith community?
Yes
No
Occasionally
Prefer not to answer
Do you have a pastor, chaplain, spiritual leader, or faith mentor you can turn to?
Yes
No
Not sure
Prefer not to answer
Sources of Strength, Hope & Meaning
What are your current sources of strength, hope, and meaning?
Relationship with God
Prayer
Scripture/Bible reading
Worship
Church/faith community
Family
Friends
Nature
Music
Service to others
Personal values
Purpose/calling
Meditation/reflection
Other
What gives you the greatest sense of hope or strength right now?
What helps you find meaning during difficult seasons?
Current Spiritual Well-Being
How often do you currently experience peace?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you currently experience hope?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you currently experience a sense of meaning or purpose?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you currently feel connected with God or a higher power?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you currently feel connected with other people?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you currently feel gratitude?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
How often do you feel spiritually resilient when facing challenges?
Often
Sometimes
Rarely
Not at all
Unsure/Not applicable
Prefer not to answer
Spiritual Distress & Struggle
Which of the following are you currently experiencing?
Feeling distant from God
Anger toward God
Questioning faith
Loss of meaning or purpose
Guilt or shame
Fear of death or dying
Difficulty praying
Spiritual loneliness
Conflict between beliefs and current circumstances
Grief
Feeling abandoned
Trouble finding hope
Uncertainty about what you believe
None
Prefer not to answer
Other
Is there a spiritual concern, question, or struggle you would like Canc3rPress to understand?
Prayer & Scripture
Is prayer meaningful or helpful to you?
*
Yes
Sometimes
No
Not sure
Would you like Canc3rPress to pray for you?
*
Yes
No
Maybe later
Optional prayer request
Would Scripture or Bible-based encouragement be helpful to you?
*
Yes
Sometimes
No
Not sure
If helpful, how would you prefer to receive it?
Brief verses
Devotional reflections
Guided prayer
Group Bible study
Individual encouragement
Not at this time
Other
Christian Faith-Based Support Preferences
Comfort level with receiving Christian faith-based support
*
Very comfortable
Somewhat comfortable
Only when I request it
Not comfortable
Unsure
Prefer not to answer
What support would you welcome?
Prayer
Scripture encouragement
Devotional content
One-on-one spiritual support
Group prayer
Bible study
Faith-based wellness sessions
Grief/spiritual support
Church/community resource connection
None at this time
Other
Spiritual Goals
Which spiritual goals would you like to strengthen or explore?
*
Deepen relationship with God
Rebuild trust or faith
Establish prayer habits
Engage more with Scripture
Find peace
Strengthen hope
Process grief
Find meaning or purpose
Reconnect with church or community
Address spiritual questions or doubts
Develop gratitude
Integrate faith with wellness
Discern next steps or calling
Other
What would spiritual growth or greater spiritual well-being look like for you over the next 3–6 months?
Support Network
Who currently supports you spiritually?
Spouse/Partner
Family
Friends
Pastor/Minister
Chaplain
Church Small Group
Counselor/Therapist
Support Group
No One Currently
Other
Would you like help connecting with any of these resources?
Pastor/Minister
Chaplain
Church Community
Counselor/Therapist
Grief Support
Other Spiritual Resource
No, thank you
Role-Specific Reflection
Role
*
Cancer Survivor
Caregiver
Oncology Clinician/Healthcare Professional
Other
How has cancer, caregiving, or oncology work affected your faith, hope, identity, purpose, fear, gratitude, or relationship with God?
What spiritual support, faith practices, or encouragement would be most helpful for you in your current role?
Safety & Scope
Supportive statement
Would you like information about additional professional or pastoral support?
*
Yes
No
Consent & Preferences
I understand that spiritual questions are voluntary and may be skipped where allowed
*
I understand
I consent to be contacted about the spiritual wellness support I requested
*
I consent
I would like to receive
Devotionals
Scripture encouragement
Prayer resources
Spiritual-wellness events
Canc3rPress faith-based program updates
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