Cancer Pathways Midwest SurveyCancer Pathways Midwest SurveyPlease fill out the following survey, your feedback helps us better serve you and your loved ones. Name(Required) First Last Phone(Required)Email(Required) Which of the following best fits your availability (check all that apply):(Required) Weekday Weekday Evening Weekend Sunday after MassSelect AllWould you need childcare?(Required) Yes NoWill you need transportation?(Required) Yes NoWhich of the following locations is most convenient for you:(Required) Cancer Pathways Midwest - 5740 Vogel Rd., Evansville, IN 47715 Your Church Downtown LocationSelect AllHow likely are you and your family to utilize our support, resources and services if provided a translator and/or a bilingual facilitator(Required) Very Likely Unsure Not LikelyWould you and your family utilize CPM support, resources and services?(Required) Yes NoIf not, please explain:What are you and your family members most interested in? Click all that apply.(Required) Confidential Counseling (Individual, Couples, Family, Child(ren) Resources (Financial, Specific Cancer Info, Treatments & Side Effects, How to talk with my kids? Types of Treatment (Surgical, Chemo, Radiation, Immunotherapy, Clinical Trials, Stereotactic Radiosurgery) Wellness (Yoga, Tai Chi, Aqua Classes, other Fitness Classes) Social Activities and Hangouts VolunteeringSelect All
