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Formerly Wellness Place

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Current Client

Current Client Form

CLIENT INFORMATION

First name*

Last name*

Birthdate*

Month

Day

Year

Email*

Phone Number*

Mailing Address*

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Preferred Contact Method(s)*

Call

Text

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HOW CAN WE HELP?

Support Request*

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Blanket

Gas Voucher

Hat(s)

Port Pillow

Program Information

Protein Powder: Berry

Protein Powder: Chocolate

Protein Powder: Vanilla

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Support Group

Wig

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How would you like to receive this/these requested item(s)?*

When do you need this/these requested item(s)?*

Person(s) approved to request and/or pick-up items on your behalf (optional)

Anything else we should know?

ON BEHALF OF A CLIENT

If you are submitting this form on behalf of a client, please fill out the information below.

Code Number (if provided)

Your First & Last Name

Your Role

Phone

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CONTACT US

Pacific Professional Building

610 N Mission Street #202

Wenatchee, WA 98801

509.888.9933

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Cancer Support Community Central Washington is a program of Wellness Place, a 501(c)(3) nonprofit organization: EIN: 91-1891688

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