Recipient Nomination Thank you for your interest in nominating your patient to the Breathing Room Foundation. It is our mission to provide services to families as they face the hardships associated with a cancer diagnosis. Please complete the nomination form and include any details that you feel might help us to assist this patient in the best way possible. NOTE: This form must be completed by a healthcare worker that is involved in the nominee's cancer care. Healthcare Involvement*I am a healthcare professional involved in the nominee's cancer care.I am not a healthcare professional involved in the nominee's cancer care.Please contact us for instruction on how to have services available to the person you wish to nominate. Phone: 215-277-1006 Email: Maryellen@breathingroomfoundation.org Press submit below and complete the contact form to be added to our mailing/email list or to be contacted by a member of our staff. Patient's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Choose one from menuBucksChesterDelawareMontgomeryPhiladelphiaPlease choose the county where the recipient resides.Phone*Cell/ Other PhoneEmail (if patient does not have email use no@email.com)* Enter Email Confirm Email Date of Birth* Age*Please enter a number from 0 to 110.Gender*MaleFemaleOtherRace*White Non HispanicAfrican AmericanHispanicAsianOtherIf other please specify*Type of Cancer*Diagnosis is:*New Diagnosis (Nominee has never been in active treatment before)RecurrenceProlonged Active Treatment due to metastisisMetastatic Disease?*Choose oneYesNoUnsureStage of Disease if knownAny additional information that might help us to classify this patient's diagnosisFamily InformationIs this family low-income?*YesNoThis information is important for grant purposes. Is the nominee employed?*Choose oneYesNot currently, but was employed prior to diagnosisNoIf the nominee is employed, please give name of employer.Has the nominee served in the military?Choose OneYesNoDoes the nominee have health insurance?*Choose OneYesNoIf the nominee is insured, specify the provider.Marital Status*Choose oneSingleMarried and living with spouseMarried but not currently living togetherTotal number of people living in the household*Number of children living in the home (age 18 and under)Please enter a number from 0 to 25.Ages of children living in the householdSpouse or Caretaker's Name First Last Relation to recipientPhoneReferred byDoctor's Name* First Last Doctor's Phone*Referred by Name* First Last Referred by Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Professional Affiliation*What hospital or healthcare facility are you affiliated with?Referred by Phone*Referred by Email* Relationship to Recipient NomineeAreas of Support Needed Basic needs (housing, utilities, food, clothing, etc.) Transportation to medical appointments Mecial Needs (prescriptions, co-pays, equipment/supplies Other Please check all boxes that apply. This is for the purpose of statistics on the needs of the patients being referred to our foundation for support. BRF will continue to call each applicant to see how we can best address their needs. Comments*Please include any additional information that might help us in providing support to this patient.