Breadcrumb Home Get Support & Education Treatment Decisions CAR T Cell Therapy Car T Navigation Referral Please use this referral form to be connected to personalized CAR T Navigation Services with the Cancer Support Community Cancer Support Helpline. You must have JavaScript enabled to use this form. Contact Type I am a patient I am a caregiver I am a healthcare professional Patient First Name Patient Last Name Caregiver First Name Caregiver Last Name Contact Information Your Email Phone Number Secondary Phone Patient Information City State Date of Birth Date of Diagnosis Cancer Type Treatment Center Secondary Treatment Center (if applicable) Preferred Language if Other Than English Areas of Concern (Choose all that apply) Need evaluation for CAR T Cell Therapy Finding or paying for a place to stay (lodging) Finding or paying for transportation to treatment center and appointments Understanding Family Medical Leave Act and Disability Caregiving concerns Limited support available Financial concerns: Insurance coverage or copay cost concerns Financial concerns: Affording costs of daily living (rent, mortgage, utilities, etc.) Food or Nutrition Concerns Seeking Emotional Support Clinical Trials Access Survivorship Educational resources Other… Enter other area of concern… Demographics Gender Identity - Select -ManWomanTrans man/transgender man/FTMTrans woman/transgender woman/MTFGenderqueer or Non-binary Primary Race - Select -Alaska NativeAmerican IndianAsianBlack/African AmericanMiddle Eastern or North AfricanNative HawaiianOther Pacific IslanderWhite Secondary Race - None -Alaska NativeAmerican IndianAsianBlack/African AmericanMiddle Eastern or North AfricanNative HawaiianOther Pacific IslanderWhite Ethnicity - Select -Hispanic/LatinoNon-Hispanic/Non-Latino Is the Patient a Veteran? Yes No In which branch did they serve? Consents If you are a healthcare professional referring, did you receive consent from the patient or caregiver to complete this application on their behalf? Yes No Name of referring professional and credentials: Healthcare professional contact information for questions or follow-up (phone/email): Does the patient, guardian or caregiver give permission for Cancer Support Community’s Car T Navigator to contact them? Yes No Does the patient, guardian or caregiver give Cancer Support Community permission to speak with a healthcare team member about their concerns? Yes No Is there any additional information you would like for us to have about the patient’s needs, concerns or support limitations: This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
