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Connect Thru Cancer Client Registration Form
If you have any questions please contact us by email at
info@connectthrucancer.org
. Please note: This organization provides programs of support to cancer patients and their families. We do not provide financial assistance.
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* Required
Client Name
*
Your answer
Client Email
*
Your answer
Cell Phone
*
Your answer
Address Street Name *needed for shipping books, cancer kits and busy bags when applicable, verify in-home support available and to track geographical reach of our programs.
*
Your answer
City
Your answer
State
Your answer
Zip
Your answer
How did you hear about Connect Thru Cancer?
Nurse Navigator
Social Worker
A Friend
CTC Website/Social Media
Other:
If you were referred by a Nurse Navigator or Social Worker, please let us know their name?
Your answer
Out of State Residents: At this time we are offering specific workbooks for cancer patients, teens and kids that can be mailed to you. We can also send a list of additional resources available to help you navigate the treatment process.
Educational Resources: Journal Workbook for patients, Teen Workbooks, Child Busy Books
Other:
Emergency Contact/Spouse
*
Your answer
Cancer Diagnosis
*
Your answer
Stage
Your answer
Treatment (check all that apply)
*
Surgery
Chemotherapy
Oral Chemotherapy
Radiation
Immunotherapy
Targeted Therapy
Hormone Therapy
Stem Cell Transplant
Precision Medicine
Required
Are you currently in treatment?
*
Yes
No
If no what is the date of your last treatment?
Your answer
What Hospital/ Cancer Center are you receiving treatment?
*
Your answer
Did you receive a Cancer Comfort Kit from your hospital system or Nurse Navigator/Social Worker?
Yes I received a Cancer Comfort Kit
No I did not receive a Cancer Comfort Kit from my hospital
I received a Cancer Comfort Kit from another source besides my hospital (from CTC directly)
Clear selection
What is the name of your Oncologist?
Your answer
Client Age
*
20-30
30-40
40-50
50-60
60+
Number of Children: Name, Gender, Age (Helps with resources appropriate for them)
*
Your answer
I am interested in learning about your in-home program (Offered weekly for 1.5 hours/week to provide creative play with young kids at home and respite to the parent) *Currently offered to the Tri-County Philadelphia Area: Chester, Delaware and Montgomery County
*
Yes
No
My kids are pre-school aged or younger but in day care during the day, but I would like to learn more about this program
For In Home Program: Child Name | Age | Gender | Special Concerns
*
Your answer
For In Home Program: Child Name | Age | Gender | Special Concerns
*
Your answer
For In Home Program: Child Name | Age | Gender | Special Concerns
Your answer
Household Income:
*
$10,000-$30,000
$31,000-$50,000
$51,000-$80,000
$81,000-$100,00
> $100,000
Ethnicity
*
White/Caucasian
Black or African American
Hispanic/Latino
American Indian or Alaska Native
Asian
Other
Would you like a phone call to learn more about our in-person programs? Specifically our in-home support programs and monthly family fun days?
*
Yes, I would like a Phone Call to learn more about your programs
Email is all I need to learn about your support
Add my email to your program list to hear about upcoming events for families
Other:
Please tell about what type of support you need most. If we do not provide that we can try to send you resources that may help.
*
In Home support for my young children at home
Talking tips to discuss my diagnosis with my children / Counseling
Financial Support
Connecting with others who are battling cancer
Monthly in person get together In West Chester for coffee and conversation with others on their cancer journey
Other
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