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 Type of Cancer*If other please specify*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 diagnosisAge*Please enter a number from 0 to 110.Date of Birth* Race*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific Islander.WhiteGender*MaleFemaleOtherFamily InformationMarital Status*Choose oneSingleMarried and living with spouseMarried but not currently living togetherIs 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.Does this patient speak English*YesNoThis information will help us when connecting with the family.If no, what language does the patient speak?Has the nominee served in the military?Choose OneYesNoTotal 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 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 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.Professional Affiliation*What hospital or healthcare facility are you affiliated with?Relationship to Recipient NomineeReferred by Email* Referred by Phone*Doctor's Name* First Last Areas of Support Needed* Basic needs (housing, utilities, food, clothing, etc.) Transportation - Please register this patient for rides through RoundTrip Transportation Service Transportation - Other than RoundTrip service (gas card, car payment, other transportation option) Nutritional supplements, incontinent supplies, durable medical equipment Other Please choose the option that is most pressing at this time. If you choose the option to register the patient in the Roundtrip (RT) transportation program, that patient will be added to the RT portal as soon as possible. Your additional comments are helpful to us when communicating with the patient. Resources are limited, however we will do what we can to support the needs of those patients referred.Comments*Please include any additional information that might help us in providing support to this patient. Δ