BCRC provides guidance, education & assistance to those living in the Texas counties of Bastrop, Caldwell, Hays, Travis & Williamson. Complete this intake and privacy policy form and let us know how we can help you.

***Para acceder a este formulario en español, haga clic aquí.***
I am seeking help...

Thank you for making a connection to Breast Cancer Resource Center. Please call our Helpline (512-524-2560) and the Program Specialist will help you with next steps. 
Your Information (1)
Thank you for reaching out to BCRC. Please fill out your contact information and our Program Specialist will contact you. 
Address
5 digit zip code only
Notice
At this time, our patient navigation services are only available for those living in the following 5 counties: Bastrop, Caldwell, Hays, Travis, and Williamson. 

Please click on the links below for resources available to anyone touched by breast cancer. 
Demographics
MM/DD/YYYY
Pronouns are the part of speech used to refer to someone in the third person. We want to know how to respectfully refer to you!

There are a wide variety of disabilities, and the ADA regulations do not list all of them. Some disabilities are visible and some are not. Some examples of disabilities include: Diabetes Post-traumatic stress disorder HIV Autism Cerebral palsy Deafness or hearing loss Blindness or low vision Epilepsy Mobility disabilities such as those requiring the use of a wheelchair, walker, or cane Intellectual disabilities Major depressive disorder Traumatic brain injury The ADA covers many other disabilities not listed here.
Cognitive disability examples include: Autism Spectrum Disorders, brain injury, and Alzheimer's. Mental disability examples include: anxiety disorders, PTSD, and depression.

Household and Employment Information
Please only enter numbers into this field. Example: 40000
Insurance
Emergency Contact Information

In case our Patient Navigators are unable to reach you for an extended period of time.

Authorized Personal Representative(s)

Consent to Contact
BCRC respects your right to confidentiality and will follow your preferences when contacting you:
(check all that apply)




Privacy Policy
By submitting this form, I agree to have a BCRC Patient Navigator contact me. I agree that I provided the information for the purpose of receiving information about resources and understand that what I provided on this form will be used for this service only. I acknowledge that BCRC has provided me an electronic copy of its Notice of Privacy Practices.  (Click here)  I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and have any questions clarified. This agreement is in effect as long as I am a BCRC client.
Distress
Distress is an unpleasant experience of a mental, physical, social, or spiritual nature. It can affect the way you think, feel, or act. Distress may make it harder to cope with having cancer, its symptoms, or its treatment. 

Please select the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.*

No distress
Extreme Distress
Have you had concerns about any of the items below in the past week, including today? (Mark all that apply)




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