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.

I am seeking help for:

Myself On behalf of someone else

What is the status of your diagnosis?

Your Information

First Name

Last Name

E-mail Address

Preferred Email

Phone

Preferred phone

Gender	Date of Birth MM/DD/YYYY	Ethnicity
Preferred Language

Street Address

Street Address 2

City

State

Zip Code

5 digit zip code only

County

No. of Household Members

Employment Status

Annual Household Income

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

Insurance Status

Type of Insurance

Insurance Provider

I consent to the following individual(s) receiving my health information as my 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.

May we identify ourselves as BCRC on your preferred phone?

I consent to being contacted by the BCRC by:

Phone

Text

Mail

(check all that apply)

How did you hear about the BCRC?

Name of Social Worker

Name of Medical Professional

Name of Organization

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
I know that I have enough money in savings, retirement, or assets to cover the costs of my treatment.....
My out-of-pocket medical expenses are more than I thought they would be ........
I worry about the financial problems I will have in the future as a result of my illness or treatment .......
I feel I have no choice about the amount of money I spend on care .......
I am frustrated that I cannot work or contribute as much as I usually do .......
I am satisfied with my current financial situation .......
I am able to meet my monthly expenses .......
I feel financially stressed .......
I am concerned about keeping my job and income, including work at home .......
My cancer or treatment has reduced my satisfaction with my present financial situation .......
I feel in control of my financial situation .......
My illness has been a financial hardship to my family and me .......

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.

I agree

Client Declines BCRC Services

Services Declined

Appearance	Change in Urination	Eating	Fevers
Memory/Concentration	Nose Dry/Congested	Skin Dry/Itchy	Tingling in Hands/Feet
Bathing/Dressing	Constipation	Nausea	Substance Abuse
Fatigue	Getting Around	Pain	Sleep
Breathing	Diarrhea	Feeling Swollen	Indigestion
Sexual	Mouth Sores