Client Registration Form - New | Cancer Care & Support

Dempsey Center›Registration Forms›Client Registration Form – New

CLIENT REGISTRATION FORM / RELEASE

Thank you for telling us about yourself. This information is used to help the Dempsey Center develop and schedule services for you. Please note, you must complete registration paperwork (including an Acknowledgment of Privacy Policy) before you can access Dempsey Center services. All responses are strictly confidential.

I am registering with Dempsey Center because:(Required)

I am a person diagnosed with cancer

I am the primary care partner for a person diagnosed with cancer

I am a family member or friend of a person diagnosed with cancer

I am grieving the cancer related loss of a family member or friend

Name of family member or friend diagnosed with cancer:

Relationship:

The name of my family member or friend lost to cancer is:

Relationship:

DEMOGRAPHIC INFORMATION

Name(Required)

First Last

Gender

Pronouns

Address(Required)

Street Address Apt # City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

MM slash DD slash YYYY

If under 18, guardian name:

First Last

COMMUNICATION & ACCOMMODATION PREFERENCES

Preferred method of messaging:(Required)

Text message

Phone Call

None

Primary Phone(Required)

Is this your cell?(Required)

Yes

Cell Phone

OK to leave a voice or text message?(Required)

Yes

I would like an interpreter(Required)

Yes

Preferred Language

Do you have any accommodations or access requirements you would like us to be aware of?(Required)

Yes

Please specify any accommodation or access requirements you would like us to be aware of

Email(Required)

Enter Email Confirm Email

You will also be added to our email list, you can unsubscribe at any time

Emergency Contact:(Required)

First Last

Emergency Contact Phone Number:(Required)

Emergency Contact Relationship:(Required)

EMPLOYMENT & INSURANCE

Information regarding Employment and Health Insurance is gathered solely for Dempsey Center grant application and funding purposes. Employment status and/or insurance coverage have no impact on one’s ability to be a client at the Dempsey Center. We will never contact your employer or insurer on your behalf, nor will we submit insurance claims for clients. All personal information provided will be kept confidential.

Employment Status:

Employed

Retired

Unemployed

Name of Employer:

Health Insurance Status:

Insured

Uninsured

Medicare

Medicaid

Self-insured

Name of Health Insurance Company:

INFORMATION ABOUT PERSON WITH CANCER

If you are not a person with cancer, please complete this section to the best of your ability about the individual with a cancer diagnosis.

Treatment Status(Required)

Pre-Treatment

Active Treatment

Post-Treatment

Maintenance

No Treatment

Other

Other Treatment Status

Treatment Types:

Select all that apply

Chemotherapy

Radiation

Surgery

Immunotherapy

Hormone Therapy

Other

Other Treatment

Type of Cancer(s)(Required)

Staging (if known)

Are you or your loved one navigating end of life care (hospice or comfort care)?

Yes

Unsure

Date of most recent Cancer Treatment(Required)

month/year

Date of most recent Diagnosis(Required)

month/year

Cancer Treatment Center and Location

Name of Primary Cancer Treatment Provider(Required)

Previous Cancer History:

Type(s) and date(s)

Additional Information:

DEMPSEY CENTER NAVIGATION

Client Journey Navigators assist clients with finding the services/programs offered by the Dempsey Center that are right for them. Clients may request to schedule a Client Journey Navigation Consultation, which are intended for individuals seeking one-time or solution-focused support around specific topics or questions. Please note this service is separate from oncology focused counseling support.

I would like assistance finding services and programs that are right for me(Required)
Yes
No

The best way to more provide assistance is
Please reach out to me
I will reach out at a later time

ANYTHING ELSE WE SHOULD KNOW?

Any additional information/concerns you would like to share?

DEMPSEY CENTER NOTICE OF PRIVACY PRACTICES

Please review our Notice of Privacy Practices by clicking the link below. It will open in a new window. You will need to return back to this window to check the box that you have read and understand.
Dempsey Center Notice of Privacy Practices

I have reviewed the Dempsey Center Notice of Privacy Practices.(Required)
Yes

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

The Dempsey Center respects your privacy and will only share information about your services or care with others when you give us permission to do so. You may use this section to authorize us to communicate with a care partner (family member or friend), medical provider, or other support person who is involved in your care.

Please note, this authorization may be helpful if you would like someone else to assist with scheduling or confirming appointments, asking questions about your services, helping coordinate your care, or communicating with Dempsey Center staff on your behalf.

Completing this section is optional. If you choose not to authorize another person or provider, the Dempsey Center will continue to communicate directly with you regarding your services and care.

I hereby authorize the exchange of written and verbal information concerning my illness, services, or care plan regarding care provided by either party between the Dempsey Center and the following provider, medical facility, or individual party:

Provider/Facility/Individual Name:

Address of Provider/Facility/Individual:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number of Provider/Facility/Individual:

Fax Number of Provider/Facility/Individual:

Effective Date:
Authorization to party above will be effective starting date below (month / year)

Expiration Date:
Authorization to party above will be terminated on date below (month / year)

Information to be Disclosed:
If applicable, I authorize the use or disclosure of information related to (please initial—required by Maine state law)

AIDS/HIV and other Communicable Disease

Alcohol and/or Drug Abuse Treatment

Mental Health Services provided by: A clinical social worker (LMSW-CC or LCSW), psychologist, counseling professional, clinical nurse specialist, or a physician specializing in psychiatry under the provision of Title 32.

If applicable, I authorize the use or disclosure of information related to (please initial—required by Maine state law)

AIDS/HIV and other Communicable Disease
Initial below:

Alcohol and/or Drug Abuse Treatment
Initial below:

Mental Health Services provided by: A clinical social worker (LMSW-CC or LCSW), psychologist, counseling professional, clinical nurse specialist, or a physician specializing in psychiatry under the provision of Title 32.
Initial below:

Purpose for Release of Information:
The purpose for releasing this information is:

Coordination of care

Other (Specify)

Specify other purpose for release of information:

I understand that I may revoke all or part of this authorization by notifying the Dempsey Center. This authorization will be retained as part of my client care record. I may refuse to disclose all or some of the information in my record. A refusal or revocation to release some or all information may result in improper assessment or treatment, denial of insurance coverage or claim for health benefits, or other adverse consequences. I may cross out any words in this authorization with which I disagree. I may have a copy of this authorization upon request. I understand that if this information is disclosed to a third party, the information may no longer be protected by the federal privacy regulations and may be re-disclosed by the person or organization that receives the information. If I refuse to sign this authorization, I understand my records will not be released verbally or in writing. This authorization will expire one year from the date I sign this form, or upon my request.

DEMPSEY CENTER CLIENT CODE OF CONDUCT

I have reviewed the Dempsey Center Client Code of Conduct.(Required)
Yes

Date
MM slash DD slash YYYY

After submitting this form successfully, you will be redirected to the Orientation Video!
In this 15-minute video, you will find all you need to know about the services offered to you at no cost here at the Dempsey Center.

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