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Needs Assessment

Sipping PositiviTEA™

We are here to provide assistance and support to individuals and families affected by Breast & Chest Cancer. Please fill out the following form to help us understand how we can best assist you.

Your information will remain confidential.

PERSONAL INFORMATION

First name

Last name

Gender

Female

Male

Other

Date of Birth

Email

Phone Number

Do you currently have Breast, Chest Cancer or another form of Cancer?

Yes

No

Type of Cancer

Date of Diagnosis

Order Diagnosis

Upload File

Supported File: Document (Max 15MB)

Current Treatment Information

Relationship to Patient

REQUESTED SUPPORT

Please check the boxes next to the types of support you are seeking:

Financial Assistance

Help with medical expenses (treatment costs, medication)

Assistance with transportation costs for medical appointments

Aid with insurance co-pays or deductibles

Support for other related financial burdens (home modifications, utility bills)

Daily Tasks and Practical Support

Meal preparation and delivery

Grocery shopping or assistance with food supplies

Household chores and cleaning services

Transportation to medical appointments

Assistance with childcare or elderly care

Help with running errands or picking up prescriptions

Emotional and Mental Support

Counseling or therapy services

Support groups or peer-to-peer networks

Educational resources about coping with breast & chest cancer

Stress management techniques and tools

Access to mental health professionals specializing in breast & chest cancer care

Complementary Therapies and Supportive Care

Massage therapy

Acupuncture or acupressure

Yoga or meditation classes

Supportive care programs or integrative medicine options

Practical Resources

Information on local breast & chest cancer support organizations and resources

Assistance with navigating healthcare systems and insurance coverage

Guidance on accessing community services and financial aid programs

Help with filling out necessary paperwork or forms

Additional Information or Special Requests

Privacy Consent

By submitting this form, you consent to Sipping PositiviTEA™ using the provided information to assess and provide appropriate support. Your privacy will be respected, and the information will only be shared with relevant individuals involved in coordinating the requested assistance.

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©2022 Sipping PositiviTEA™ is a non-profit organization with a 501(c)(3) tax-exempt status.

All rights reserved. Sipping PositiviTEA™ does not provide medical advice, diagnosis, or treatment.

See additional information.

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