BCRC provides guidance, education & assistance to those living in Travis, Williamson, Hays, Bastrop & Caldwell counties. Complete this intake and privacy policy form and let us know how we can help you.
Your Information








MM/DD/YYYY








5 digit zip code only




Data collected for grant purposes only & to see if you qualify for financial assistance.



Emergency Contact Information

This will be used only by our Patient Navigators in rare instances that they cannot reach you.





Authorized Personal Representative(s)

Consent to Contact
In the event that BCRC must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve your confidentiality. Please list your preferred phone number and how you would like us to identify ourselves. For example, you may request we call you at home or work, but not say the name BCRC or the nature of the call, leaving only the first name of the staff person calling. If you do not provide this information to us in the area below, we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name BCRC. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify BCRC (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines.
(check all that apply)




Distress
Distress is an unpleasant experience of a mental, physical, social or spiritual nature. It can affect the way you think, feel, or act. Distress may make it harder to cope with having cancer, its symptoms or its treatment. Please select the number (0-10) that best describes how much distress you have been experiencing in the past week including today.*
No distress
Extreme Distress
Please indicate if any of the following has been a problem for you in the past week, including today. (Select all that apply)




* NCCN Distress Thermometer and Problem List for Patients by the National Comprehensive Cancer Network® (NCCN®)
Financial
Below is a list of statements that other people with your illness have said are important. Please select the number to indicate your response as it applies to the past 7 days.
Not at all   1 A little bit  2 Somewhat 3 Quite a bit 4 Very much 5
* COST: A FACIT Measure of Financial Toxicity Copyright 2014, FACIT and The University of Chicago
By submitting this form, I agree to have a BCRC Patient Navigator contact me. I agree that I provided the information for the purpose of receiving information about resources and understand that what I provided on this form will be used for this service only. I acknowledge that BCRC has provided me an electronic copy of its Notice of Privacy Practices.  (Click here)  I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and have any questions clarified. This agreement is in effect as long as I am a BCRC client.

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