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 individual's cancer care. If you encounter any issues, please give us a call at 215-277-1006 or email Mary Ellen at maryellen@breathingroomfoundation.org.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 Patient InformationPatient'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.Best Contact Number*Please give best contact numberDescriptionCell PhoneHome PhoneOther ContactAlternative NumberEmail (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*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific Islander.WhiteIf 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?*YesNoUnsureStage 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 OneYesNoMarital 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 recipientPhoneDoes this patient speak English*YesNoThis information will help us when connecting with the family.If no, what language does the patient speak?Referred byReferred 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?Health System (if applicable)*Choose OneACSAspire Health SystemCHOPDoylestown HospitalEinstein Health SystemHoly RedeemerJefferson Health SystemMain Line Health SystemPenn Health SystemTemple HealthTrinity Health SystemVA Medical CenterOtherPlease choose the appropriate choice or choose other.Referred by Phone*Referred by Email* Relationship to Recipient NomineeDoctor's Name* First Last Areas of Support Needed* Basic needs (housing, utilities, food, clothing, etc.) Transportation - Please register this patient for rides through RideRoundTrip Transportation Service Transportation - Other than RoundTrip service (gas card, car payment, other transportation option) Nutritional supplements, incontinent supplies, durable medical equipment Other Please check all boxes that apply. Comments*Please include any additional information that might help us in providing support to this patient.