First Time Visitors Form

All of Our Programs Are Currently Virtual Due to COVID-19.

Your data is kept confidential at Hope Connections. Your information will never be sold or shared with a third party.
Email*
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Today's Date
MM slash DD slash YYYY
Personal & Contact Information
Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Woman
- Man
- Transgender
- Non-binary/non-conforming
- Prefer not to respond
Address*
Street Address City State ZIP Code
Primary contact number*
Primary contact number type*
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Additional contact number
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Additional contact number type
I am:*
About
Please complete the following for yourself or for the person you are here to support.
Cancer Diagnosis-Click to select*
Is the cancer a recurrence?*
- Yes
- No
Is the cancer metastatic?*
- Yes
- No
Name Of Patient If Not Self
First Last
Date diagnosed*
MM slash DD slash YYYY
Oncologist's name*
First Last
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Hospital (name and location)*
Primary Treatment Hospital or Center*
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Hospital and Treatment Centers (select all that apply):
- Adventist Healthcare, Shady Grove
- Adventist Healthcare, White Oak Medical Center
- Anne Arundel Medical Center
- Aquilino Cancer Center
- Frederick Health Hospital
- George Washington University Hospital
- Holy Cross Hospital, Germantown, MD
- Holy Cross Hospital, Silver Spring, MD
- Johns Hopkins, Baltimore, MD
- Johns Hopkins, Sibley, DC
- Johns Hopkins, Suburban Hospital, Bethesda, MD
- Howard County General
- Inova Schar Cancer Institute
- Kaiser Permanente, Capitol Hill Medical Center, DC
- Kaiser Permanente, Largo, MD
- Luminis Doctors Community Medical Center, Lanham, MD
- Maryland Oncology and Hematology
- MedStar Georgetown, DC
- MedStar Southern Maryland, Clinton, MD
- MedStar Shah Medical Center, Waldorf, MD
- MedStar Washington Hospital Center, DC
- Mercy Medical Center, Baltimore, MD
- National Institutes of Health (NIH)
- University of Maryland Medical Center, Baltimore, MD
- Walter Reed, Bethesda, MD
- Other (see next)
If other, please list your primary treatment hospital or center:*
Emergency Contact Information
Emergency contact name*
First Last
Cell Phone Number*
Relationship
Additional Information
Please note: Attendance at an orientation is required before attending Support Groups and Mind/Body classes. Unless otherwise noted, all of our programming are for those age 18 and over. Comfortable clothing and physician approval recommended for all exercise Mind/Body Classes.
Which of our programs are you interested in attending? Choose all that apply:*
- Support Groups
- Mind/Body Classes
- Educational Programs
- Social Events
- Volunteer Opportunities
How did you hear about us? Check all that apply:*
- Doctor
- Nurse
- Social Worker
- Maryland Oncology and Hematology
- Family
- Friend
- Employer
- Internet
- Newspaper/Magazine
- Radio
- TV
- Hope Connections Staff/Volunteer
- Other
Referral Name*

Please write the name of the person who referred you, or n/a if not applicable.
Would you like to receive our quarterly program calendar and information on upcoming programs and special events via email?*
- Yes
- No
Hope Connections reserves the right to refuse to provide services to participants and to allow participants to engage in Hope Connections programs who violate or threaten to violate Hope Connections’ policies, are threatening or disruptive to staff or other participants or who appear to present a potential danger to the participant, staff or other participants.
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Our Programs are Free. Your Donations Make this Happen!

Become part of our community, whether or not you have cancer. Learn how you can help Hope Connections ensure that those with cancer get the support, caring, and compassion they need.

Make a Difference

First Time Visitors Form

First Time Visitors Form

Personal & Contact Information

About

Emergency Contact Information

Additional Information

Our Programs are Free. Your Donations Make this Happen!