Client Application 2025-Cape Wellness Collab

Client Application 2025

You may be eligible for our services if: -You are a resident of Barnstable, Nantucket, or Duke's Counties -You have received a cancer diagnosis within the last 12 months -You are currently undergoing or recovering from cancer treatment such as radiation and/or chemotherapy -You have had positive genetic testing results for inherited cancer risk and are undergoing prophylactic surgery such as mastectomy and or oophorectomy To be eligible for our 6-week Wellness Eats program, you must meet the following additional criteria: -You are currently receiving active cancer treatment (i.e. chemotherapy and/or radiation treatment) and/or are less than 1 month post cancer related surgery. -You have no known dietary allergies or food aversions

I confirm that I have read the eligibility requirements above and understand the criteria for application approval.

First Name

Last Name

Date of Birth

Applicant Email

Phone Number

Physical Address (NO P.O Box #)

Mailing Address (P.O. Box number)

How did you hear about CWC?

Where are you being treated?

What type of cancer have you been diagnosed with?

When did you receive your diagnosis?

Are you currently undergoing, or do you anticipate undergoing, chemotherapy or radiation therapy

Yes

Unsure

What type of treatment are you currently receiving, and when was your most recent session? (If you are not undergoing active treatment, please enter N/A.)

250

Have you undergone surgery related to your oncology care? If yes, please specify the type of surgery and the date.

250

Which integrative wellness therapies are you interested in using, and how do you see them benefiting you?

500

Kindly share a bit about yourself and your current situation.

600

Please provide us with the name of your Doctor/Oncologist.

I give Cape Wellness Collaborative permission to contact my oncologist or medical professional to confirm a recent, past, or present diagnosis, or a confirmed genetic predisposition.

The mission of Cape Wellness Collaborative is to provide integrative therapies to people in our community facing cancer. We require all members applying for services to consult with their primary oncologist before starting any and all therapies. If your application for services is accepted, we will provide you with a link to a list of vetted practitioners - and a system by which to pay them for any service you select. The mention of any product, service, or therapy is not an endorsement by Cape Wellness Collaborative, nor is it intended to substitute for the medical expertise and advice of your primary healthcare provider and/or oncologist.

Cape Wellness Collaborative does not discriminate in its programs or activities on the basis of race, color, national or ethnic origin, ancestry, age, religious creed, disability or handicap, sex or gender, gender identity and/or expression, sexual orientation, military or veteran status, genetic information, or any other characteristic protected under applicable federal, state or local law.

RELEASE AND AGREEMENT

The undersigned member requests the assistance of Cape Wellness Collaborative, Inc. (CWC) in identifying providers (hereinafter "Provider(s)") of services including, but not limited to, acupuncture, massage, meal services, nutritional counseling, Reiki, meditation and yoga (collectively "services"), so that such Providers can render services to the Member. I understand that CWC does not, in any way provide actual services.

Member hereby acknowledges and understands that CWC makes referrals only to Providers who are licensed and insured in their respective fields. Member acknowledges that they should consult with their medical professionals regarding the appropriateness of the requested services.

In consideration of Cape Wellness Collaborative identification of possible Providers:

a) After consideration of the risks inherent in Provider's services, Member fully assumes any and all risks associated with Member's participation in any and all Provider services, and;

b) Member further agrees to waive and release any and all claims that Member or their respective heirs, have, or may have in the future, against CWC, its agents, servants, directors, officers, and employees for any losses, damages, expenses, or injuries, including death, suffered from, or in any way, in connection with Member's participation in any and all Providers services.

Records of any identity, prognosis, or treatment shall be privileged and confidential in accordance with the Massachusetts Privacy Act and the privacy rules of the Health Insurance Portability and Accountability Act (HIPPA).

I acknowledge reading, understanding and agreeing to the above provisions.

What is your preferred method of contact?

Phone

Who is completing this application?

I am the applicant.

I am completing this on behalf of the applicant.

Your Name: