Part 1. ONLINE APPLICATION FOR CWC SERVICES Home Phone Cell Phone Email
How did you hear about CWC?
Where are you being treated? Beth Israel Deaconess Medical Center Brigham & Women's Hospital Cape Cod Healthcare Dana Farber Cancer Institrute Mass General Hospital Other
Would your personal caregiver like for our caregiver specialist to reach out to them?
As part of our initiative, Cape Wellness Collaborative is affiliated with Certified Caregiving Consultant™ Louisa Stringer. Providing your caregiver’s name and contact information will allow Louisa to reach out on your behalf with more information about our free caregiver support services. Wellness Cares
What is your current treatment plan? Check all that apply.
Surgery date, if applicable Chemotherapy date range Radiation date range
Are you interested in receiving organic, nutritionally-crafted prepared meals? If yes, you may qualify for our
As part of our Wellness Eats program eligible clients can apply for a 4-week program which provides delicious, organic, nutrient-dense, ready-to-eat meals, free of charge. Our current program includes 3 meals a week for 4 weeks, for both the person facing cancer and their caregiver. To be eligible for our Wellness Eats program, clients must meet the following criteria:
Currently receiving active cancer treatment (i.e. chemotherapy and/or radiation treatment) and/or are less than 1 month post-surgery
A resident of Cape Cod
A Cape Wellness Collaborative recipient
Have no known dietary allergies or food aversions
Are you interested in group yoga classes? If yes, you may be interetsed in our
program. Wellness Moves
I give Cape Wellness Collaborative permission to contact my oncologist or medical professional to confirm a recent past or present cancer diagnosis or a confirmed genetic predisposition.
The mission of Cape Wellness Collaborative is to provide complimentary/integrative therapies to people in our community facing cancer. We require all clients applying for services to consult with their primary oncologist before starting any and all therapies. If your application for services is accepted, we will provide you with a link to a list of vetted practitioners – and a system by which to pay them for any services you select. The mention of any product, service or therapy is not an endorsement by Cape Wellness Collaborative, nor is it intended to substitute for the medical expertise and advice of your primary health care provider and/or oncologist.
Cape Wellness Collaborative does not discriminate in its programs or activities on the basis of race, color, national or ethnic origin, ancestry, age, religion or religious creed, disability or handicap, sex or gender, gender identity and/or expression, sexual orientation, military or veteran status, genetic information, or any other characteristic protected under applicable federal, state or local law.
RELEASE AND AGREEMENT
The undersigned client requests the assistance of Cape Wellness Collaborative, Inc. (CWC) in identifying providers (hereinafter "Provider(s)") of services including, but not limited to, acupuncture, massage, meal services, nutritional counseling, Reiki, meditation and yoga (collectively "services"), so that such Providers can render services to the Client. I understand that CWC does not, in any way provide actual services.
Client hereby acknowledges and understands that CWC makes referrals only to Providers who are licensed and insured in their respective fields. Client acknowledges that they should consult with their medical professionals regarding the appropriateness of the requested services.
In consideration of Cape Wellness Collaborative identification of possible Providers:
a) After consideration of the risks inherent in Providers services, Client fully assumes any and all risks associated with Clients' participation in any and all Provider services, and;
b) Client further agrees to waive and release any and all claims that Client or their respective heirs, have, or may have in the future, against CWC, its agents, servants, directors, officers and employees for any losses, damages, expenses, or injuries, including death, suffered from, or in any way, in connection with Clients' participation in any and all Provider services.
Part 2. SURVEY
We ask that you complete the following baseline survey as part of your application. The information you provide is completely confidential and will help us improve our services.
1-Breast 2-Cervical 3-Colorectal 4-Lung 5-Ovarian/Uterine 6-Pancreatic 7-Stomach 8-Lymphoma/Leukemia 9-Liver 10-Other When did you receive your diagnosis?
In this questionnaire you will be asked about your symptoms. Would you please, for all symptoms mentioned, indicate to what extent you have been bothered by it, by selecting the number (1 - 4) most applicable to you.
1 = not at all
2 = a little
3 = quite a bit
4 = very much
PLEASE ONLY RESPOND WITH A NUMBER (1, 2, 3 or 4) AND NOT A TEXT ANSWER
Have you, during the past week, been bothered by:
lack of appetite irritability tiredness worrying sore muscles depressed mood lack of energy low back pain difficulty sleeping nervousness nausea despairing about the future headaches vomiting dizziness decreased sexual interest tension abdominal (stomach) aches anxiety constipation diarrhea acid indigestion shivering tingling hands or feet difficulty concentrating sore mouth / pain when swallowing loss of hair burning / sore eyes shortness of breath dry mouth
A number of activities is listed below. We do not want to know whether you actually do these – only whether you are able to perform them presently. Would you please mark the answer that applies most to your condition over the past week.
1 = unable
2 = only with help
3 = without help, with difficulty
4 = without help
care for myself (wash, etc.) walk about the house light housework/household jobs climb stairs heavy housework/household jobs walk out of doors go shopping go to work 1-excellent 2-good 3-moderately good 4-neither good nor bad 5-rather ppor 6-poor 7-extremely poor Would you please check whether you answered all the questions?
Our CWC client care representative will be in contact to answer any questions you may have.