MAINE ORIENTATION INQUIRY AND REGISTRATION

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 prefer my orientation to be:(Required)
If you are interested in completing an orientation in-person in Lewiston or South Portland OR virtually with a member of our team, please press “Back” on your browser and select the “In-Person or Virtual Orientation” option.

INFORMATION

Name(Required)
Address(Required)
MM slash DD slash YYYY
Are you over the age of 18?(Required)
Email(Required)
You will also be added to our email list, you can unsubscribe at any time
OK to leave a voice or text message?(Required)
Preferred method of messaging:(Required)
Emergency Contact:(Required)
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:
Health Insurance Status:
Please provide information about your or your loved one’s cancer diagnosis

DISTRESS THERMOMETER

As defined by a feeling of extreme worry, sadness, or pain, please select the number on the thermometer that best describes how much distress you have been experiencing in the past week, including today.

Thermometer
My distress level is:

COMMON CONCERNS

Below is a list of common concerns experienced by patients and family members. Please check the items you are presently experiencing.

Emotional Concerns
Please select all that apply
Physical Concerns
Please select all that apply
Family Concerns
Please select all that apply
Practical Concerns
Please select all that apply
One on One Consultations
Complementary Therapies
Types of Classes + Workshops
Support

Please review our Privacy Policy 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 it and then click Submit.

MM slash DD slash YYYY

Dempsey Center Client Code of Conduct

Please review our Code of Conduct here… Dempsey Center Client Code of Conduct
I have reviewed the Dempsey Center Client Code of Conduct.(Required)

Securing Form

SECURING FORM