General Support Application Form – Inner Compass Cancer Foundation
If you are interested in receiving any of our support services, please complete this form. We offer nutritional, emotional, and financial assistance to people affected by cancer. Your information helps us understand your situation and we will contact you to continue the process.
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Full Name
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Age *
Email Address
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Phone Number
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City and Country of Residence
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Preferred Language
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What is your cancer diagnosis?
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What is the current stage of your cancer? 
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Who is your current healthcare provider?
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Are you currently receiving treatment?
Clear selection
What treatments have you received so far? (Check all that apply)
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Required
What are your future treatment plans? 
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Are you currently employed?
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Are there other people who contribute financially to the household (partner, children or other relatives)?
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How many people contribute financially to the household?
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How many people depend on you financially?
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Do you go to medical appointments or treatments accompanied? If yes, who usually accompanies you to medical appointments?
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What type of housing do you currently live in? (rented, owned, borrowed, other.)
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Does your home have access to drinking water?
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Does your home have access to electricity?
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Do you consider your home to be a suitable space for your recovery?
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Does your home have access to necessary hygiene resources? (for example: towels, alcohol, gloves, masks, among others)
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How far away is the center where you receive treatment?
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How do you usually get to your medical appointments? (public transport, own vehicle, family or friend, taxi or private service)
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Do you have health insurance?
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What type(s) of support are you interested in?
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Required
What would you like to achieve through this service? 
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Are there any other needs or difficulties you would like to share so we can better support you?
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How did you hear about Inner Compass?
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Privacy Notice and Consent
All information will be kept confidential and only used to evaluate your application for support. Submitting this form does not guarantee that support will be approved. If selected, we will contact you using the information provided.
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