Cancer therapies for the body, mind and spirit.

• Name: *
• Street: *
• City: *
• State: *
• ZIP: *
• County: *
• Phone: *
• Email: *
•  I would like to receive email updates about HTI and its activities.
• Birth date: *
• Where did you hear of our program?

Date of initial cancer diagnosis (mm/yy):*
What was your initial diagnosis?*
Has there been a major change in your diagnosis or a recurrence of cancer more recently?*

 Yes No
If so, describe, including the date of this occurrence
Facility where you are being treated and Doctor’s name:*
Check any treatment that you are currently receiving:
 Chemotheraphy infusions Radiation therapy Oral maintenance drug Wait and watch

• Is this your first application to HTI? * YesNo
•  Please check here if you are able to afford a small fee of $15 per massage (to be paid to the massage therapist at the time of service). Contributing in this way is NOT required to receive services, but if your financial situation allows it, we would appreciate your help in making our resources go further.
•  I understand and acknowledge that Human Touch Initiative, Inc. makes no representation or warranty with respect to any of the services I receive from its participating providers, and I agree to look solely to the individual provider in the event that I am dissatisfied in any way with the services I receive. *
• I certify that the information that I have provided to Human Touch Initiative is accurate and truthful to the best of my knowledge.

  Your Initials *