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NetofCare Online Registration Form

NetofCare welcomes your organization to join our database of services. Please use the form below to describe your organization and its services. You will receive a notice of the status of your submission via e-mail.


* Required Fields
Organization Information
*Name of Organization
*Address
*City    *State    *Zip
*Phone ( - 
Toll-free Phone ( - 
Fax ( - 
Web-site
Email
Do you want your email published online?  

Services Offered - check all that apply
Advocacy
  Help with illness-related job discrimination
Legal assistance
Patient advocacy assistance
 
Counseling and supportive services
  Phone
In-Person
Self-help and peer support
Spiritual counseling
Problem solving/case management
Counseling for patients
Counseling for friends and family members of patients
Counseling for caregivers
Bereavement counseling
Psychiatric services
Referrals
 
Information and education
  Newsletters
Publications
Disease specific information
General information
Programs for patients
Programs for friends and family members of patients
Programs for caregivers
Programs for professionals
Computer and Internet access for the public
Resource center for the public
Library for the public
 
Medical Treatment
  Referrals for Care: Treatment Centers
Referrals for Care: Physicians
Clinical trials
Palliative care
Pain clinic
Fatigue clinic
Wellness program - screening and preventative care
On-site nursing care

Other, please specify:
 
 
Rehabilitation
  Physical therapy
Occupational therapy
Employment counseling
Supplies and equipment
Referral to a rehabilitation program
 
Home Care
  Hospice Care
Non-Hospice
Volunteers: Friendly Visitors
Childcare
 
Out-of-home Care
  Adult day healthcare
Senior Center
Psychiatric Day Treatment
Residential Care Facility
Intermediate Care Facility
Nursing Home (Skilled Nursing Facility)
Other specialized care facilities
Respite care
 
Childrens services
  Please specify if any:
 
 
Elder services
  Please specify if any:
 
 
Housing
  Providers
Referrals
Financial assistance
 
Transportation
  Providers
Referrals
Financial assistance
 
Financial Assistance
  Direct financial assistance
Entitlement and benefits assistance
Health insurance information
Assistance with medications
 
Complementary and Alternative therapies
  Acupuncture
Yoga
Massage

Other, please specify:
 
 
Stress reduction and self-care therapies
  Relaxation techniques
Guided imagery and visualization techniques

Other, please specify:
 
 
Specific illnesses treated
  Amyotrophic Lateral Sclerosis (ALS)
HIV/AIDS
Alzheimer's Disease
Brain and neurological injuries and illnesses
Cancer
Heart disease
Lung disease
Sickle Cell disease

Other, please specify:
 
 
Region served
  National organization

Other, please specify state and country:
 

Agency Description
Description of organization:
 
Description of services:
 
Description of population:
 
Description of population needs:
 
Please provide any additional information here:
 
Agency's interest in community education
  Advance directives
Care options at the End-of-Life
Goals of care in progressive illness
Pain management
Role of caregivers

Other, please specify:
 
 
Caregiver's (patient/client) online capabilities -(check if answer is yes)
  Do patients/clients have access to a personal computer in your agency?
If so, is the personal computer in a public place?
Do they have a personal computer at home, or work (if known)?
Do they know how to use a personal computer?

What activities and functions do they perform on the computer (if known)?
 
  Do they know how to obtain information from the internet?

If they obtain new information, do they take action based upon the information? If so, what actions do they take?
 

Prepared by:
*Name   
Title

Person to contact for database updates (If different from above):
 
 
 

 

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