Lend A Helping Hand Questionnaire by maclaren1

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									                             Lend A Helping Hand Questionnaire
In order for your request to receive full consideration, please
complete entire packet, sign on the designated lines in the
presence of a witness, and return to the address printed at the
bottom of this page.

Name: _____________________________________ Age: _________________
Home Address: ____________________________________________________
e-mail: ___________________________________________________________
Daytime Phone: __________________ Evening Phone: __________________
Referring Physician (Oncologist/ Radiologist): _________________________
Physician’s Address: ________________________________________________
Physician’s Phone: _________________________________________________
Primary Treatment Facility: __________________________________________
Nurse / Social Worker: _____________________________________________
Diagnosis: ____________________ Date Diagnosed: _____________________
Current Treatment: ________________________________________________
How is your request from Lend a Helping Hand related to your Breast Cancer?
_________________________________________________________________
_________________________________________________________________
Have you ever received assistance through the Lend a Helping Hand program
or a similar program? _______
If so please indicate the organization’s name and assistance received.
__________________________________________________________________
Please describe any special medical needs or considerations that might pertain to
the applicant’s request_______________________________________________

As best you can estimate, please indicate what you feel will be the most desir-
able date(s) for the services requested.

On__________________ or between ______________and ______________
      (Month / Day / Year)               (Month / Day / Year)   (Month / Day / Year)


  P.O. Box 184, Miller Place, NY 11764   631) 255-2401 info@northshoreneighbors.org

                         www.northshoreneighbors.org
                                     Lend A Helping Hand Questionnaire

I understand and agree that any representative of the NSNBCC regarding
the requested assistance has made no promises or assurances whatsoever
to me.

I understand and recognize that the granting of any service and the par-
ticipation of any person in the project is contingent upon the approval
by the NSNBCC as well as compliance with all conditions, qualifications
and restrictions designated by the NSNBCC.

I also understand that there is a limit to the number of services that I
will receive, depending upon the type and cost of service being re-
quested and offered.

________________________ ________              ____________________ _________
Participant               Date                 Witness              Date

________________________ _________ ____________________ __________
Additional Signature      Date      Witness             Date
(If participant is unable to sign)




    P.O. Box 184, Miller Place, NY 11764    631) 255-2401 info@northshoreneighbors.org

                                www.northshoreneighbors.org
                                   Lend A Helping Hand Questionnaire

Please choose the service that would best suit your needs:

______ Catering; Dinner delivered to your home

______ Housecleaning Service

______ Transportation Service to/from breast cancer related treatments and ap-
        pointments.

______ Massage Therapy

______ Day of Beauty

______ Salon Services, such as a manicure, pedicure, etc.

______ Dinner Out

______ Childcare

______ Other (please explain) ________________________________________

_________________________________________________________________
Frequency and time allotments of the service you’ve chosen will differ depending on many variables. Your Lend
a Helping Hand Volunteer will explain the number of service dates available to you during your initial phone
consultation.




                   Program funded in part by a grant from the Long Island 2 Day Walk To Fight Breast Cancer.
                                   For more information please visit: www.li2daywalk.org



   P.O. Box 184, Miller Place, NY 11764                  631) 255-2401 info@northshoreneighbors.org

                              www.northshoreneighbors.org

								
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