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Hope Lives! was created to assist individuals undergoing breast cancer treatment by alleviating the physical, emotional, and financial side effects of treatment.


PLEASE ANSWER EACH QUESTION COMPLETELY BEFORE SUBMITTING TO ENSURE THAT YOUR APPLICATION GETS REVIEWED. THIS INCLUDES, COUNTY, ZIPCODE, AND OTHER QUESTIONS THAT ARE ASKED. PARTIAL APPLICATION WILL CAUSE A DELAY. PLEASE TAKE THE TIME TO READ AND ANSWER EACH QUESTION THOROUGHLY!


Reminder: Clients must be in active treatment to qualify.  

Please complete the application in its entirety and click the submit button.

 

Questions? Email Debbi Potts, Program Manager, at debbi@hopelives.org or call our office at (970) 225-6200


* Indicates required question

Hope Lives! New Client Application

Have you been a Hope Lives! client before Yes or No?
Yes
No

Note:   * Please enter your full name "with a space" between your first, middle initial and last name.

Note:   * Please enter complete address below "with a space" between Address, City, State, County, Zip Code.

* Hope Lives! reserves the right to communicate with this individual after a phone or email attempt to contact you has been unsuccessful.


* Please enter "with a space" between Name, Phone, Relationship.

* Please enter "with a space" between your DOB & Age.

Gender
Male
Female
First Breast Cancer Diagnosis?
Yes
No
Date of Diagnosis
Month
Day
Year

* Please enter "with a space" between Stage and Type of Breast Cancer

Your answer.


* Please enter "with a space" between Physician Name and Navigator/Social Worker Name.

What Services are you interested in? Mark all that apply
Regarding my care and treatment, I, hereby verify that I am in the care of my physician and that under their supervision I am receiving or will receive treatment for breast cancer in the form of:

VERIFICATION OF TREATMENT

Please note:

- Mammosite Radiation or Hormonal Therapy are not qualifying therapies

- Reconstruction is not covered by our program.

* Please Label with Date and enter "with a space" between each one.

The below section is required to be completed but is not a determinant of eligibility. We use this information to collect data. You will not be disqualified from the program based on your income.

DIAGNOSIS STATUS

I understand that it may be necessary to verify my medical status

Annual Household Income
$0- $10,000
$10,001- $25,000
$25,001- $40,000
$40,001- $60,000
$60,001- $75,000
$75,001- $90,000
$90,001- Over
Prefer not to say
How do you identify racially and ethnically?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Prefer not to say
Other
Marital Status
Single
Domestic Partnership
Married
Widowed
Prefer not to say
Do you have Health Insurance?
Yes
No

Hope Lives! is considering a support group and your answers to the following questions will help us know how to best serve you.

Are you interested in attending a monthly support group for women with breast cancer?
Yes
No
Would you prefer the support group to be...
Virtual
In person
Not interested
Would you be able to attend this support group from 5:15PM-7:00PM?
Yes
No
Not interested

New Client Application Rules & Agreement

Date
Month
Day
Year
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Thanks for Submitting!

Contact Us

Hope Lives! adds quality of life to breast cancer patients by offering integrative support services and products that help manage the physical, emotional, social & financial side effects of breast cancer treatment. Contact us if you want to learn more!

Thanks for submitting!

ADDRESS

2627 Redwing Rd, Suite 210

Fort Collins, CO 80526

PHONE

970.225.6200

EMAIL

info@hopelives.org

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