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?
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Previvor
No Diagnosis
Initial Diagnosis
Progression
Recurrence
Survivorship
Survivorship > 5 years
Other cancer diagnosis (not breast)
Your Information
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County
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No. of Household Members
Employment Status
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Employed
Unemployed
Retired
Annual Household Income
Data collected for grant purposes only & to see if you qualify for financial assistance.
Insurance Status
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Insured
Uninsured
Type of Insurance
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Private Plan
Medicaid
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MAP
Insurance Provider
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Blue Cross/Blue Shield
United Healthcare Insurance Company
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Other
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?
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Yes
No
I consent to being contacted by the BCRC by:
Phone
Text
Email
Mail
(check all that apply)
How did you hear about the BCRC?
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Medical Professional
Social Worker
Friend/Relative
Other Organization
BCRC Outreach Event
BCRC Website
Fundraising Event
News Broadcast
Publication
Facebook/Twitter
Name of Social Worker
Name of Medical Professional
Name of Organization
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
0
1
2
3
4
5
6
7
8
9
10
Extreme Distress
What best describes your treatment status?
Please select...
Newly diagnosed have not started treatment
Surgery
Chemotherapy
Radiation
Post Treatment
Metastatic Breast Cancer
Please indicate if any of the following has been a problem for you in the past week, including today.
(
Select all that apply
)
Practical Problems
Child Care
Housing
Insurance/Financial
Transportation
Work/School
Treatment Decisions
Family Problems
Dealing with Children
Dealing with Partner
Ability to have Children
Family Health Issues
Emotional Problems
Depression
Fear
Nervousness
Sadness
Worry
Loss of Interest in Usual Activities
Physical/Spiritual
Physical Problems
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
Spiritual/Religious Concerns
Spiritual/Religious Concerns
Other Problems
* 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
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
.......
* 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.
I agree
Client Declines BCRC Services
Services Declined
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