Building on Love Screening Questionnaire

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

The patient named in the application must be a child under the age of 18.

YesNo

The patient named in the application has been RECENTLY diagnosed with a life altering illness and is in active treatment. Our goal is to engage with families within 120 days of initial diagnosis.

YesNo

The family resides in one of the counties served by our approved referral partners: Albany, Columbia, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington. *(We also will consider applications for inpatient families being treated at The Bernard & Millie Duker Children's Hospital who reside outside of the above counties).

Albany Medical Center - NICU (Neonatal Intensive Care Unit)Albany Medical Center - The Melodies Center for Childhood Cancer and Blood DisordersAlbany Medical Center - PICU (Pediatric Intensive Care Unit)Albany Medical Center - OtherRonald McDonald House Charities of the Capital Region, aka Albany Ronald McDonald HouseNYOHCDPHPOther

The family was financial stability prior the life-altering diagnosis.

YesNo

The family is facing a demonstrable loss of income due to missed work.

YesNo

Please choose which answer best describes the family's current financial situation:

The family is still financially stable (not behind on any household bills)The family is starting to fall behind on their bills (some bills due this month are past due)The family is significantly behind on their bills (some bills are more than one month past due)

This form will be sent to Jeff Yule (Executive Director for Building on Love) for review. He will follow up with you within 24 hours.

You will also receive a copy of this submission which will be sent to the email provided on the form.