Cancer Services of Northeast Indiana Corporate Client Intake Form

Cancer Services of Northeast Indiana

Cancer Services of Northeast Indiana

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Matching grant worth $200,000
The Madge Rothschild Foundation has issued a challenge grant to all donors offering a $1 for $1 match on every gift pledged to the capital campaign before June 30, 2008. For more information, please contact Dianne May at 260-484-9560.

Nutrition Seminar
August 14, 2008
5:30 p.m. to 7:00 p.m.
Healing Arts Center at Cancer Services of Northeast Indiana
Abby L. Black, RD, CDE, Clinical Dietitian from Lakeland Healthcare, St. Joseph, MI, will present "When you have Cancer AND Diabetes"

An Evening of Sharing,
A Lifetime of Caring
SAVE THE DATE
September 25, 2008
Mariott Marquis Ballroom
An evening gala where each table is named in tribute of an individual who has been touched by cancer, a caregiver or physician. Jen McDevitt, Brain Cancer Survivor and Dr. Henry Friedman will be the featured speakers. For more information contact Brenda S. Betley at bbetley@cancer-services.org or 260-484-9560.

Cancer Services of Northeast Indiana Client Intake

Client Intake Form

Directions: You may use the online Client Intake form below for yourself or for the person who has cancer if s/he is unable to come to Cancer Services. Or, you may click here to download and print the Client Intake form to fill out by hand.

In order to begin services, we do ask that a consent form be signed by the person with cancer. Special arrangements can be made for home visits. Please call if you have questions:
(260) 484-9560 or (866) 484-9560.

Client Intake (All information remains confidential)

(FOR CHILD INTAKE, PLEASE ENTER CHILD'S NAME, AND WHAT S/HE PREFERS TO BE CALLED.
REMAINDER OF INFORMATION IN THIS SECTION THEN REFERS TO PARENT/GUARDIAN.)

Last Name: First Name: M.I.

Name you prefer to be called? e-mail:

Home Address: City: County:

State: Zip:

Home Phone: -- Cell: --

Social Security #: --

Spouse/Significant Other OR Parent/Guardian:

Spouse/Significant Other's Cell Phone: --

Emergency Contact (not living in home):

Emergency Contact Phone: -- Relationship:

Address: City: State: Zip:

Demographics of Client/Child Client

Gender: Male Female

Date of Birth (mm/dd/yyyy): // Age:

Veteran? Yes No

Marital Status: Married Single Significant Other Widowed Divorced

The race/ethnicity with which Client most identifies (please check):

African American American Indiana or Alaskan Native Asian

Hispanic or Latino Native Hawaiian or other Pacific Islander White

Other (please specify):

Annual household income range of Adult Client OR Child Client's Parent/Guardian:

$0-$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000

$50,001-$60,000 $60,001-$70,000 $70,001-$80,000 $80,000 +

Number of people dependent on that income?

MEDICAL INFORMATION ON CLIENT

Cancer Diagnosis:

Date of Diagnosis (mm/dd/yyyy): //

Has it metastasized (spread)? Yes No

If yes, where has it spread?

Cancer Physician (Oncologist/Radiologist):

Please check if the client has received any of the following cancer treatments:

Surgery Radiation Chemotherapy Hormones Other:

List dependents/dependent siblings living in home (if any):

Name: Date of Birth (mm/dd/yyyy): //

Employment Information of Client or Child Client's Parent/Guardian

Current Employer: Work Phone: --

Employer Address: City:

State: Zip: Phone: --

Position:

Spouse/Significant Other's Employer:

Employer Address: City:

State: Zip: Work Phone: --

Insurance Information

Client's Medicare #: Client's Medicaid #:

Insurance Company: Address:

City: State: Zip: Phone: --

ID#: Group #:

Other Insurance:

Additional Information

Person filling out form: Relationship to client:

How did you hear about Cancer Services: (Please check all that apply & specify if able):

Hospital: Physician:

Radiation at Lutheran Hospital Radiation at Parkview Hospital

Ft. Wayne Medical Oncology & Hematology Friend/Relative

Home Health Care/Hospice: Other:

Please review your information and click the Send button below.
We will acknowledge receipt of your form as soon as possible.

Cancer Services of Northeast Indiana

Cancer Services of Northeast Indiana · 2925 East State Blvd. · Fort Wayne, IN 46805
Phone: (260) 484-9560, Toll Free: (866) 484-9560, FAX: (260) 484-9572
webmaster@cancer-services.org