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Home » Application for Patient Advocate Liaison Services (English)

Application for Patient Advocate Liaison Services (English)

If you or someone you know needs a Patient Advocate Liaison (PAL) please fill out the form below:

LLBCF uses the following information to help determine need for free services. All information is kept confidential, unless otherwise stated.

Date*
MM slash DD slash YYYY
Name*
First Last
Date Of Birth
MM slash DD slash YYYY
Age
Please choose your status
Address
Street Address City ZIP Code
Home Phone
Cell Phone
Work Phone
Best number to call
- Home Phone
- Cell Phone
- Work Phone
Best time to call
- Morning
- Afternoon
- Evening
Email
Do you have access to a computer?
Prefered method of contact
- Email
- Phone Call
- Letter
Ethnicity/Race
- Caucasian
- African American
- Hispanic
- Asian
- Other
How do you identify?
Who referred you to us today?
Have you ever used Libby's Legacy for breast health services?
Employment Information
Are you currently employed?
Do you work
Who is your employer?
If you are not working, why not?
Health Information
Do you have insurance?
Oncologist/Physician/Clinic

**WE CAN REFER YOU TO A PHYSICIAN IF YOU DON'T HAVE ONE**
Clinic Address
Street Address City State ZIP Code
Clinic Phone
Are you currently undergoing any treatments?
Please explain (include number of days per week and location of treatment facility)
Do you currently have a support system through either family or friends?
What services do you need:
- Advocacy for treatment
- Representative to attend appointments/treatment sessions
- Support group
Your Emergency Contact
Name
First Last
Relationship
Phone
After submitting this form, please allow 1-2 days for processing
I have read and understand the above and declare the information furnished by me is true and complete to the best of my knowledge. I consent to the exchange of information between Libby’s Legacy Breast Cancer Foundation and other community agencies to provide needed services.
Name
This field is for validation purposes and should be left unchanged.

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TAX ID#: 11-371266 Solicitation Registration #: CH25850: A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE 1-800-435-7352 WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.

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