• Image field 121

  • Client Intake Form

  • Thank you for contacting I Will Survive, Inc. We will do our best to meet the needs of your request. Please anwser the following questions for a complete assessment into our programs

  • Personal Information

  • Today's Date
     - -
  •  -
  • Housing
  • Are You Employed?*
  • Employment Status
  • Would You Like Assistance With Re-Employment
  • Household Income (Please include all benefits such as social security, child support, unemployment, etc)*
  • Have You Applied for Temporary Disability ?*
  • U.S. Citizen
  • Resident of Georgia*

  • Medical Information

  • Does Breast Cancer Run In Your Family?*
  • When Were You Diagnosed?*
     - -
  • Do You Conduct Your Self- Breast Exams Monthly?*
  • Do You Need a Reminder?*
  • Do You Get A Pap Check Up?*
  • Do You Have The BRCA Gene?*

  • Gas Card Qualification

  • Do You Have A Vehicle To Get To And From Appointments?*
  • Do You Have A Caregiver To Get You To And From Appointments?*

  • IWS Programs

  • Please Check One*
  • Financial Freedom to Fighters (Please check all that apply)
  • EmpowerHER Workshop Program (Please check all that apply)
  • Beyond the Diagnosis Program (Please check all that apply)

  • Signature and Submission

  • Thank you for allowing I Will Survive, Inc. to assist in your survival. 

    Please remember to find ways to reduce stress. Continue to eat healthy (especially during chemotherapy and radiation) and excercise (minimally during chemotherapy and radiation), reduce alchohol (none during chemotherapy and radiation) and stop smoking. 

    By signing this document you are agreeing that all the information you provided is true to the best of your knowledge. 

  • Please type your name below to indicate consent.

  • Should be Empty: