BTG4Hope Client Intake Form

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Bridging the Gap for Hope provides resource navigation and information — not medical advice or emergency services. If this is an emergency, call 911. All resources are provided virtually (delivered by email).

Full name *

Phone number *

Preferred contact method *

We’ll use this to reach you and talk through your packet.

Phone call

Text

Who is this request for?

Myself

Someone else

Clear selection

If for someone else, your relationship to them

ZIP code *

Year of birth (of the person receiving help) *

Race / ethnicity (of the person receiving help)

Some health conditions are more common in certain racial or ethnic groups, so this helps us find the most relevant resources for you. This is optional.

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Prefer not to say

Other:

What kind of services are you looking to find? (select all that apply) *

The lists show common conditions each specialty treats, to help you find the right one. For "Other," describe the type of care or specialist — do NOT list any medical diagnosis.

Long-Term & Palliative Care — comfort-focused care for serious or chronic illness

Hospice — end-of-life comfort care and family support

Bereavement Support — grief support after the loss of a loved one

Infant Death

Child Death

Adult Death

Cardiac — heart disease, heart failure, high blood pressure, irregular heartbeat

Neurology — stroke, seizures, migraines, Parkinson’s, MS, dementia/Alzheimer’s

Pulmonary — asthma, COPD, pneumonia, sleep apnea, TB

Gastroenterology — acid reflux/GERD, IBS, Crohn’s/colitis, ulcers, liver disease

Endocrinology — diabetes, thyroid problems, osteoporosis

Nephrology — kidney disease, kidney failure, dialysis

Urology — bladder, kidney stones, prostate

Oncology — cancer of any type

Hematology — anemia, clotting disorders, sickle cell, leukemia

Rheumatology — rheumatoid arthritis, lupus, gout, fibromyalgia

Orthopedic — fractures, arthritis, back/spine, joint replacement

Dermatology — rashes, eczema, psoriasis, skin cancer

Allergist/Immunology — allergies, asthma, immune disorders

Infectious Disease — TB, HIV/AIDS, sepsis, serious infections

OBGYN / Women’s Health — pregnancy, childbirth, reproductive & women’s health

Men’s Health — prostate, low testosterone, ED, general men’s wellness

Pediatric — children’s health

Geriatrics — older-adult care, dementia, mobility, multiple conditions

Psychiatric — depression, anxiety, bipolar, PTSD, schizophrenia (with medication)

Counseling / Therapy (tell us the type below)

Drug / Alcohol Rehab — substance use and addiction recovery

Rehabilitation — physical, occupational, or speech therapy

Dental

Optometry — eye exams, vision, glasses

Clinical Trial (tell us the kind below)

Other:

Required

If you selected Counseling / Therapy, what type?

For example: individual, family, couples, child.

If you selected Clinical Trial, what kind are you looking for?

Is the person currently in a hospital or care facility?

Yes

Clear selection

If a discharge is coming up, what is the expected discharge date?

We use this to get resources to you before discharge. Leave blank if it does not apply.

YYYY

Insurance *

Medicaid

Medicare

Employer/private

Marketplace

Tricare

None

Not sure

Anything else you’d like us to know? (optional)

Please leave out any medical diagnosis or prescription details. It’s okay to ask a general question about a medication to get general information — just please don’t tell us that a doctor prescribed it. This keeps your request private and helps us help you.

Submit

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