First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Date of Birth
*
Gender
*
Female
Male
Phone
*
Email
*
Marital Status:
*
Single
Married
Divorced
Separated
Widowed
Number of People in household, Adults:
*
Race/Ethnicity
*
African American
Asian
Native American/ Alaskan
Pacific Islander
Caucasian
Hispanic/Latino
Other
Previously applied for assistance from NBM?
*
Yes
No
If yes, date received
*
Rent/Mortgage
*
Transportation
*
Groceries
*
Utilities
*
Recovery Items
*
Other (Specify)
*
Employment Status
*
Employed, full time
Employed, part time
Unemployed
Self-employed
Homemaker
Student
Unable to work
Retired
If applicable, employer:
*
Annual Household Family Income:
*
$0
$1-9,999
$10,000-19,999
$20,000-34,999
$35,000-49,999
$50,000-74,999
$75,000-99,999
Over $100,000
Do you have insurance?
*
Yes
No
If yes, what is the name of your insurance company?
*
Military Status: Are you active duty or retired military?
*
Yes
No
If so are you eligible for VA Benefits?
*
Yes
No
Type of Cancer
*
Stage of Cancer
*
Date of Diagnosis (Most CURRENT diagnosis)
*
Relapse of Cancer
*
Yes
No
If Yes, Original Type & Date
*
Name of your Doctor
*
Are you currently receiving treatment?
*
Yes
No
If No, when will you start treatment?
*
What type of treatment are you receiving?
*
Date treatment began
*
Length of treatment (estimate if possible)
*
Medical facility where you receive treatment
*
How did you hear about Needs Beyond Medicine?
*
Did a person or medical office refer you to us? Please name:
*
Their Phone number:
*
Their Address
*
City
*
State
*
Zip
*
Applicant Signature
*
Date
*
Submit
