Intake Information

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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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Intake Information

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