Application 

Welcome to the Michelle’s Love Organization.  This application is lengthy, please look at it, get your answers in order and then fill out correctly with your Health Care Professional.

Answering the following questions will help us learn how to best help support you through cancer treatment. 

The mission of Michelle’s Love is to be a part of your support team through cancer treatment.  We understand cancer treatment can be lengthy with unexpected challenges.  Michelle’s Love is able to support single parents for up to 6 months. It is important to build a plan for financial independence beyond the resources Michelle’s Love provides.


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Patient Name and DOB?
 *
Phone Number?
 *
Email Address *
Current Address
 *
Time at the current address? *
Do you rent or own? 
Rent
 *

Is the patient current on rent or mortgage payments?

 *
What are the ages of the children living in the home?
 *
Who lives in the home, please include all members of household?
 *
Cancer Diagnosis?
 *
Date of diagnosis?
 *
Treatment practice/ facility?
 *
Name of Primary Oncologist?
 *
Name of Surgeon if applicable? *
Name of Radiation Oncologist if applicable? *
Current plan for cancer treatment ( surgery, chemotherapy, immunotherapy, radiation etc)
Thyroidectomy
 *
Estimated length of treatment if known?
Day surgery with at least 10 days of recovery time. 
 *
Where were you working a the time of diagnosis?
Length of employment? *
Position at current employment? *
How many hours per week were you working prior to cancer diagnosis? *
Gross monthly income? When working. *
Did you file tax returns the previous year? *
Do you have a car?
yes
 *
Car payment amount? *
Car insurance amount? *
List your monthly bills including utilities.  *

Do you receive child support or alimony (This will not disqualify you from our support)

-if so, what are the monthly amounts



 *
What is the verbal or written custody arrangement with your former partner? *
 Do you have any pets in the home. Please list all pets. Are they spayed or neutered? Current on vaccinations? *
Would you like assistance cleaning and organizing your home? *
Is the condition of your home causing you stress? *
If yes, please describe the circumstances so we can best serve you. *
Do you have advanced directives or a living will? *
If no, would you like assistance with this process? *
Do you have a support network including families, friends, co-workers, etc in place? *
Health Care Professional Work place, name, phone #, and email?

 *
Thank you, we will be in touch within two business days.
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