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Nick's House Application
Contact Information
Patient Name
*
First Name
Last Name
Email
*
Verify Email
*
Permanent Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Primary Phone
*
Secondary Phone
Date of Birth
*
(mm/dd/yyyy)
Social Security #
*
Gender
*
Male
Female
Non-Specific
Annual Income
*
Enter numbers only, do not include $, commas or spaces
Employer
*
Occupation
*
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship with Patient
*
Emergency Contact Primary Phone
*
Emergency Contact Secondary Phone
Arrival Date at Nick's House
*
Monday through Friday between 9am and 3pm
Departure Date from Nick's House
*
Monday through Friday 9am to 12pm
Diagnosis
*
Date of Diagnosis
*
(mm/dd/yyyy)
Do you have health insurance?
*
Yes
No
Do you have a prescription drug plan
*
Yes
No
Do you have medicare?
*
Yes
No
Do you have Medicaid (Title 19)
*
Yes
No
Treating Physician Information
Hospital Where Receiving Treatment
*
Treating Physician Name
*
Prefix
First Name
Last Name
Suffix
Physician Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Physician Phone #
*
Physician Email
Verify Email
Authorization to Contact
*
By clicking this button, you authorize HEADstrong Foundation to contact your medical team to validate this application and you have made them aware of your application for a stay at Nick's House
I authorize
Patient Professional Reference
*
First Name
Last Name
Patient Professional Reference Phone
*
Patient Professional Reference Relationship with Guest
*
Patient Tshirt Size
*
Small
Medium
Large
XL
XXL
YL
Other Guests Staying with Patient
Caregivers Name
*
First Name
Last Name
Caregiver Birth date
*
(mm/dd/yyyy)
Caregiver Primary Phone
*
Caregiver Relationship with Patient
*
Caregiver Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Caregiver Email
*
Verify Email
*
Caregiver Professional Reference
*
First Name
Last Name
Caregiver Professional Reference Phone
*
Caregiver Professional Reference Relationship with Caregiver
*
Caregiver Tshirt Size
*
Small
Medium
Large
XL
XXL
YL
Additional Guests
*
Do you have more guests then just the caregiver staying with you?
Yes
No
Guest 1 Name
*
First Name
Last Name
Guest 1 Birth Date
*
(mm/dd/yyyy)
Guest 1 Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Additional Information
Will patient or any guest require special accommodation?
*
Nick's House is ADA handicapped accessible.
Yes
No
If "Yes" please explain
*
Please explain how housing services from the HEADstrong Foundation will assist with financial hardship caused by your medical condition
*
Electronic Certification
I certify that I meet all the requirements below
*
Residency applicants must meet ALL the following eligibility requirements to stay at Nick's House.
Undergoing cancer treatment at time of application
Traveling at least 50 miles one way from Philadelphia, 19103
Minimum of 3 day stay required at Nick's House
All applicants must have a permanent residence to return to after staying at Nick's House
All patients staying at Nick's house must be accompanied at all times by an adult caregiver capable of meeting the daily care needs of the patient. Patients without an appropriate caregiver will not be permitted to stay at Nick's House.
A criminal background check is required for all guests, including the patient, who are 18 years of age or older. A link to complete the background check will be sent to each adult's email address as listed on this form.
*
By clicking below, you are providing consent for us to reach out to you for a background check. This must be completed prior to our approval for your stay at Nick's House.
Agree
I agree to the terms and conditions as stated below
*
Nick’s House is not a healthcare facility and may not be used for the purpose of the administration of medical care or therapies, including, without limitation, palliative or hospice care. HF makes its residential facilities available for such persons from time to time, in the HF’s sole discretion. Use of residential facilities is subject to the rules and requirements of HEADstrong Foundation. All residents must sign a Nick’s House Guest Agreement, the form established by the HF. Length of stay is up to 6 weeks, extensions may be approved at the discretion of the board.
I agree
The undersigned certifies the below
*
The undersigned certifies to HF that he/she meets the eligibility requirements of the Nick’s House Residential Services Program, as described in this Application, and that all the information provide in or with this Application is true and correct.
I agree
