Cancer Connect In-Take Form - Byrd Cancer Education and Advocacy Foundation

Get Connected to Support

The Cancer Connect Navigator Program is here to support you every step of the way. Whether you’re a patient, caregiver, or family member, we are committed to working with you to connect you to the resources that address your unique needs. From emotional support to financial assistance, we are here to help you navigate your journey.

How It Works:

Fill out the intake form below with your information and the type of support you’re seeking.
A member of our team will review your submission and connect you with the appropriate resources.
We’ll follow up to ensure you’re receiving the support you need and provide additional assistance if necessary.

Additional Note: All information shared is confidential and used solely to provide you with the best possible support.

Let us help you navigate your cancer journey

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Personal Information

Full Name *

First

Last

Pronouns (if applicable)

Gender at Birth *

Gender Identity *

Date of Birth *

Email Address *

Phone Number *

living Are they

What is your race? *

Black or African American
White or Caucasian
American Indian or Alaska Native
East Asian
South Asian
Southeast Asian
Native Hawaiian or Other Pacific Islander
Mixed Race

Other

What is your ethnicity? *

Hispanic/Latino
Not Hispanic or Latino
Asian
European
African
African American
Caribbean American (non-African descent)
Afro-Caribbean
Irish
Middle Eastern or North African

Other

What is your primary language/dialect?

What is your secondary language (if applicable)?

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact Name *

Emergency Contact Number *

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Family and Social History

Are you a parent? *

If yes, How many children and ages?

Do you have siblings? *

If yes, Ages

Do you have a family history of cancer? *

Yes
No
Unsure

If yes, Who in your family?

What age were they diagnosed?

What type of cancer did they have?

Did they have genetic testing? *

Yes
No
Unsure

Social Living Situation

What is your current living situation? *

Living alone
Living with family
Living with friends/roommates
Homeless
Assisted living or nursing home

Other

Do you feel safe in your current living situation? *

If no, please explain

Occupation & Financial Status

Are you currently employed? *

Yes, full-time
Yes, part-time
No, unemployed
On medical leave
Self-employed
Retired
Disabled

Does your cancer diagnosis affect your ability to work? *

If yes, how?

Are you facing financial challenges due to your diagnosis? *

If yes, please describe

Do you have a support system in place (friends, family, community)?

If yes, who is part of your support system? (check all that apply)

Spouse/Partner
Children
Parents
Friends
Extended family
Religious or community groups

Other

Are you satisfied with your current level of support?

Would you like to be connected with additional support services or groups?

Lifestyle Habits

Do you smoke or have you ever smoked?

Never
Yes, currently
Yes, but quit

Do you drink alcohol?

Never
Occasionally
Regularly
Yes, but quit

Do you use recreational drugs?

If yes, please specify

Physical Activity

Do you engage in regular physical activity?

Yes
No
Occasionally

What type of physical activities do you do?

Walking
Running
Yoga
Strength training

Other

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Cancer Diagnosis and Treatment

What type of cancer do you have? (Check all that apply) *

Breast Cancer
Lung Cancer
Colorectal Cancer
Prostate Cancer
Stomach Cancer
Liver Cancer
Esophageal Cancer
Thyroid Cancer
Bladder Cancer
Non-Hodgkin Lymphoma
Other

Other, please be specify

How old were you when you were diagnosed? *

Where did you live when you were diagnosed? (please list full address/location, if applicable) *

Current Treatment Plan *

Chemotherapy
Radiation
Surgery
Immunotherapy
Hormone Therapy
None

Other

Where are you receiving treatment? (Name of hospital/clinic) *

Are you currently in remission? *

Are you receiving palliative care? *

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Medical Information

Medications (related to cancer treatment)

If yes, please list

Do you have health insurance?

If yes, What type of insurance? (Private, Medicaid, Medicare, etc.)

Are you receiving financial assistance?

If yes, from where?

Allergies

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Support Needs

What do you need help with? (check all that apply)

Cleaning my house
Laundry
Lawn care
Junk removal
Gas/Transportation
Food
Counseling
Ways to cope and de-stress
Support groups
Childcare
Daycare

Bills (please specify) (check all that apply)

Mortgage/Rent
Co-pays
Utilities

Other (please list)

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Emotional and Mental Health

Have you been referred to or are you currently working with a counselor or therapist?

How are you feeling emotionally? (e.g., anxious, overwhelmed, hopeful, isolated)

Would you be interested in speaking with a mental health professional?

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Wellness and Additional Support

Would you be interested in wellness programs?

Nutrition Counseling
Massage Therapy
Yoga

Other

Do you need help with preparing meals?

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Caregiver Information

Do you have a primary caregiver?

If yes, What is their relationship to you?

Would your caregiver benefit from any support services?

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Cultural and Religious Preferences

Are there any cultural or religious considerations important to you during your cancer journey?

If yes, please specify

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Additional Needs

Would you be interested in receiving help with genetic counseling or testing?

Are you currently receiving any community support? (e.g., church, community centers):

Do you need help with legal matters related to your diagnosis? (e.g., employment rights, medical leave, estate planning)

How do you prefer to receive support?

In-person
Virtual
Hybrid

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Email *

Get Connected to Support

Let us help you navigate your cancer journey

Personal Information

Family and Social History

Social Living Situation

Occupation & Financial Status

Lifestyle Habits

Physical Activity

Cancer Diagnosis and Treatment

Medical Information

Support Needs

Emotional and Mental Health

Wellness and Additional Support

Caregiver Information

Cultural and Religious Preferences

Additional Needs

Cancer Information

Resources & Support

About Us