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.

***Para acceder a este formulario en español, haga clic aquí.***

I am seeking help...

Who are you seeking help for?:

Myself Someone else

What is the status of your diagnosis?

PrevivorNo DiagnosisInitial DiagnosisProgressionRecurrenceSurvivorship Survivorship > 5 yearsOther cancer diagnosis (not breast)

What do you know about your diagnosis?

What do you know about your treatment plan?

Is there anything that stands out as especially worrisome or stressful that you would like the navigator to know?

Your Information

First Name

Last Name

E-mail Address

Preferred Email

PersonalWorkOther

Phone

Please enter numbers only (no dashes or parentheses)

Preferred phone

HomeMobileOther

Date of Birth

Please enter numbers only. No slashes.

What are your pronouns?

Other Pronouns

Gender

Ethnicity

Preferred Language

Other Preferred Language

Do you identify as a person with a disability or other chronic condition (not including your breast cancer diagnosis)?

YesNoPrefer not to say

How would you describe your disability or chronic condition?

Military Service

Do you consider yourself a member of the LGBTQIA+ community?

YesNoPrefer not to say

Address

Street Address

Street Address 2

City

State

Zip Code

5 digit zip code only

County

Household and Employment Information

No. of Household Members

Employment Status

EmployedUnemployedRetired

Annual Household Income

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

Insurance

Insurance Status

Type of Insurance

Private PlanMedicaid MedicareMAPMedicaid for Breast and Cervical Cancer (MBCC)

Insurance Provider

Emergency Contact Information

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

Name

Relationship

Phone

Authorized Personal Representative(s)

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?

YesNo

May we leave a message on your preferred phone?

YesNo

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

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 12345678910

Extreme Distress

What best describes your treatment status?

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/FinancialTransportationWork/SchoolTreatment DecisionsFood

Family Problems

Dealing with Children Dealing with PartnerAbility to have Children Family Health Issues

Emotional Problems

Depression FearNervousnessSadnessWorryLoss 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®)

Healthy Lifestyle

Healthy Lifestyle Questionnaire

Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days do you feel your mental health was good?

Thinking about your physical health, which includes physical activity and injuries, for how many days during the past 30 days do you feel your physical health was good?

Currently how often do you smoke cigarettes or use other tobacco products, including vaping, compared to before your cancer diagnosis?

Less oftenThe same amountMore oftenI didn’t do this before my diagnosis and I still do not now

Currently how often do you engage in physical activity, compared to before your cancer diagnosis?

Less oftenThe same amountMore oftenI didn’t do this before my diagnosis and I still do not now

Currently how often do you eat healthy foods, compared to before your cancer diagnosis?

Less oftenThe same amountMore oftenI didn’t do this before my diagnosis and I still do not now

Currently how often do you take vitamins and/or supplements, compared to before your cancer diagnosis?

Less oftenThe same amountMore oftenI didn’t do this before my diagnosis and I still do not now

Did you have a primary care provider (PCP) before your cancer diagnosis?

YesNo

Do you currently have a primary care provider (PCP)?

YesNo

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.