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Intake Information
Personal Information
First Name
Birthday
Gender
Address
City
State
ZIP Code
Phone Number
Email Address
Preferred Method of Contact
Emergency Contact
Name
Relationship to Client
Phone Number
Email Address
Background Information
Have you or your family been affected by a parent or caregiver with cancer? If yes, please provide details.
Are you currently undergoing cancer treatment yourself and recommending a loved for the support groups? If yes, please provide details.
Are you currently receiving support from any other organizations or healthcare providers? If yes, please provide details.
Are you currently in therapy or seeking professional counseling?
Support Preferences
What type of support are you seeking? (e.g., individual mentoring, support groups, educational workshops)
Do you have any specific preferences or requirements for the support services you receive?
Are there any specific topics or issues you would like to address during your sessions?
Availability
Please provide your availability for appointments (days of the week and times?)
Consent
I understand that the information provided on this form will be used to assess my needs and preferences for support group services from Linda’s Way. I consent to the collection and use of this information for the purpose of providing me with support. I understand that my personal information will be kept confidential in accordance with Linda's Way privacy policy
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