Contact Request: Initial Assessment of Need
Here at MFITF, we are here to make sure you are supported through treatment and beyond. In order to do this safely and effectively, we need to start by asking you a few questions to begin your FREE cancer coaching. This organization is fully volunteer operated and if at any time you are able to donate towards our services, we would greatly appreciate it. Now, LET'S GET STARTED!
**All info is HIPAA Compliant**
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Email *
Name *
Address (city, and zip are required) *
1 point
Phone Number *
1 point
Preferred Method of Contact *
Required
Date of Birth XX/XX/XXXX *
1 point
Gender *
Allergies to Medications *
Please list all medications your currently taking, including supplements, vitamins, and over the counter medications. *
Type of Cancer *
Stage of Cancer *
Treatment Plan for Cancer (List treatments you have received or are planning to receive per your cancer doctors). *
Current List of Physicians/Hospital System You Are Working With: *
Primary Support Person/Emergency Contact and Phone Number: *
Services I am interested in: *
Required
What are the primary concerns? (I.e. pain, fatigue, finances, etc.) *
How did you hear about us? *
A copy of your responses will be emailed to the address you provided.
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