WCRC General Client Intake

Welcome! If you are new to WCRC, or have not completed an intake form previously, please take a moment to fill out this form. In addition to helping us understand and serve our community, completing this form helps keep our services 100% free. We appreciate your support!

Please know that we do not sell any information you share with us.

(Be sure to click submit at the very bottom when you are done.)

We do not provide crisis support services and we are limited in our ability to provide community resource support for those outside of the Bay Area but we will do our best to assist you.
Date

MonthDayYear
Date
Program

Support GroupsWellness WorkshopsPatient NavigationI&R HelplineNo-Cost Counseling/TherapyOther
Name (staff/volunteer) of person completing this form (leave blank if you're filling this out for yourself)

First NameLast Name
Phone Number of person completing the form

Area CodePhone Number
Email of person completing the form
example@example.com
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Date of first contact with WCRC (in person, online, or on the phone)*

MonthDayYear
Date
How did you hear about WCRC?*

Brochure/FlyerDoctor/Nurse/Social WorkerInternet SearchFamily MemberFriendDecline to stateTabling Event/OutreachOther
I am a:*

Person with cancer/have had cancerSupport person for someone who has/has had cancerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Cell or home?*

CellHome
Alternate Phone (cell or home)

Area CodePhone Number
Okay to leave a voice message?

Yes, and it's okay to say we're calling from Women's Cancer Resource CenterYes, and it's okay to say we're calling from WCRCNo
We want to make sure you stay connected. Please choose how you would like to receive WCRC information: (check all that apply)

By mailBy emailBoth
I would like to sign up to receive a:

Monthly e-newsletterMonthly e-calendarQuarterly print calendarnone
Email (if no email, please enter, "unsure or does not apply")
example@example.com
Email (if no email, please enter, "unsure or does not apply")*
example@example.com
Emergency Contact

Area CodePhone Number
Name and Relationship to Emergency Contact
Client's Primary Language
# of people in the household*
Race/Ethnicity (check any that apply)*

White/CaucasianAfrican-American/BlackLatino/Latina/LatinxNative American/American Indian/Alaska NativeArab/Middle EasternAsian/South Asian/Asian AmericanPacific IslanderDecline to stateOther
# of children in the household under 18*
Gender (check any that apply)*

FemaleMaleNon-binaryTransgenderAgenderGender non-conformingGender fluidTwo-SpiritDecline to stateOther
Gender Pronoun (check any that apply)*

She/herHe/himThey/themDecline to stateOther
Sexual Identity*

Heterosexual/StraightLesbian/GayBisexualQueerPansexualAsexualDecline to stateOther
If you have NOT been diagnosed with cancer, please complete the cancer-related questions on behalf of the person with cancer in your life for whom you are completing this intake form.
Type of Cancer*
Date of Diagnosis*
Stage*
Metastasis?*

YesNoUnsureDecline to state
If yes, location of metastasis
Treatment (check any that apply)*

ChemotherapySurgeryRadiationImmunotherapyDecline to stateNoneOther
Alternative Treatment (check any that apply)*

Massage TherapyAcupunctureMindfulnessNutritionMedical CannabisDecline to stateNoneOther
Treatment Details
Do you have an oncologist?*

YesNoDecline to state
If yes, provide oncologist name and hospital/cancer care location (include city)
Do you have a social worker?*

YesNoDecline to state
If yes, social worker name and location
Medical Insurance*

Medi-CalMedicareHMO/PPO (private insurance)Decline to stateNoneOther
Medical Provider*

Alta BatesAlameda Health SystemCarol Ann Read Breast CenterContra Costa Regional Medical Center/Martinez Health CenterEpic CareKaiserHighlandJohn MuirStanfordSutter HealthUCSFI don't recallNoneOther
Medical Plan Name (e.g. Kaiser, Blue Cross-Anthem, Aetna; if Covered California, note note name of insurance provider.)
Annual household income below $30,000?

YesNoDecline to state
My annual household income is:*

Below $30,000$30,000 to $45,000Above $45,000Decline to State
In the last six (6) months, have you been concerned that you might run out of food for the week?

YesNoDecline to state
In the last six (6) months, have you run out of healthy food or had limited access to healthy food?

YesNoDecline to state
Would you like assistance accessing food resources?*

NoYesMaybe
Do you have stable housing?

YesNoUnsureDecline to state
If no or unsure, current situation:
Would you like assistance accessing housing resources?*

YesNoMaybe
Services/Resources Needed

What services and resources can we assist you with?
Screening Support

Breast cancerCervical cancerOther
Diagnostic Support

Breast cancerCervical cancerOther
Treatment Support

Clinical trialsHelp coordinating and/or accessing treatmentHospiceWellness WorkshopsOther
Financial Support

Emergency financial assistanceHelp applying for benefits
Emotional Support

Support groupTherapy/counselingPhone calls from a volunteerSupport for a family member
Practical Support

HousingFoodWigs/ProsthesesIn-Home Care ServicesOther
Additional Notes
Transportation

Rides to medical appointments (Please note: WCRC does not provide rides to appointments as a standalone service.)Discounted public transportation
Women’s Cancer Resource Center
wcrc@wcrc.org ✦ 510.601.4040
2908 Ellsworth Street, Berkeley, CA 94705
Should be Empty:

Services/Resources Needed