IWS Client Intake Form

Client Intake Form
Thank you for contacting I Will Survive, Inc. We will do our best to meet the needs of your request. Please anwser the following questions for a complete assessment into our programs

Signature and Submission
Thank you for allowing I Will Survive, Inc. to assist in your survival.

Please remember to find ways to reduce stress. Continue to eat healthy (especially during chemotherapy and radiation) and excercise (minimally during chemotherapy and radiation), reduce alchohol (none during chemotherapy and radiation) and stop smoking.

By signing this document you are agreeing that all the information you provided is true to the best of your knowledge.
Please type your name below to indicate consent.
Client's Signature*
Date*

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Client Intake Form