Patient Assistance

If you are in need of assistance, please complete the form below. Questions about eligibility may be directed here.

Please allow three weeks for us to review the information and get in touch with you.

1 Step 1

First Name

Last Name

Street Addressinclude apartment number

City

StateFunding for Greater Charlotte area only

Select An OptionNCSC

Zip Code

Phone

Email

Age

Number of ChildrenLiving in the home

Race/EthnicityOptional

Hispanic/LatinoAsianNative AmericanNative Hawaiian/Pacific IslanderAfrican AmericanWhite/CaucasianMixed RacePrefer not to answer

Marital StatusOptional

Date of Breast Cancer Diagnosis

Breast Cancer Type/Subtype

Current Stage

Select An OptionStage 0Stage IStage IIStage IIIStage IVUndesignated

Name of Oncologist

Are you currently undergoing active treatment?surgery, chemotherapy, and/or radiation

YesNo

Please describe your treatment plansurgery, chemotherapy, and/or radiation

0 /

Length of Treatmentinclude specific dates and/or estimated timeframe (example: 6 chemotherapy treatments starting March 7 every 3 weeks)

0 /

Treatment Facility

Insurance Provider

Current Yearly Household Incomeinclude spouse/partner earnings

Employment Status

Full TimePart TimeUnemployedRetiredDisabled

Employer

If not currently working, describe reason:Select all that apply

Treatment schedule prohibits workingRecovering from treatmentFMLAReceiving Short Term DisabilityReceiving Long Term DisabilityRetiredDisabledOther (please describe below)

Other

Are you working with a Social Worker or Patient Navigator?

Yes No

May we contact your Social Worker or Patient Navigator on your behalf?

YesNo

List Name of Social Worker or Patient Navigator

Social Worker or Patient Navigator's Email

email

How did you hear about Go Jen Go?

Select An OptionHospital/Healthcare Provider (Doctor, Nurse, Navigator, Social Worker)Go Jen Go WebsiteFamily/FriendsAnother PatientEventSocial MediaOther (please specify below)

Other:

Please select the form of assistance most helpful in your current circumstancesSelect one

Monthly StipendSingle Allocation of Funds

What is your Primary financial need right nowSelect one

Mortgage/Rent Utilities Transportation Groceries/Necessities

Mortgage/Rent $per month

Average Utilities $per month

Transportation Costs $per month

Groceries/Necessities $per month

Please describe your request for assistance in detail and outline your need (include amounts of any bills past due)*Medical bills are not an expense covered through Go Jen Go assistance

0 /

I hereby attest that the information provided in this application is true, accurate, and complete and that I am the person who is the subject of the application or have been authorized to act on behalf of the applicant.

Signatureyour full name

Date

If not patient:your full name

Relationship to Patient:

Parent or GuardianSpouse or PartnerFamily MemberSocial WorkerPatient NavigatorHealthcare ProviderOther

Please attach medical documentation of diagnosis and treatment plan *required for application to be complete

cloud_uploadUpload medical letter (REQUIRED)

Upload other pertinent files hereoptional

cloud_uploadUpload past due bills

Applications for assistance are reviewed twice a month. You will receive an update or request for additional information typically within 3 weeks of your application submission. 

Questions can be directed to meredith@gojengo.org and jessie@gojengo.org.

Submit Application for Assistance

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I’m writing to thank you guys again for all your support and assistance. DJ had the best x-mas ever and I was able to use the donations, gas cards to get around and take care of some important things. I’m feeling great and doing well emotionally/ physically and can’t wait until doctors release me to return to work. DJ will be turning 4 this Sunday and I still have some of the gifts from you guys saved to give him on his birthday. Today I met with the cancer oncologist and well the verdict is in… I do need chemo and will be starting cycles hopefully by the end of the month. I was also writing to ask for your assistance again with gas cards for my appointments, and if possible some help with funds. I asked my case manager of any resources or agencies that can help w/ car note or insurance but was unsuccessful in finding any. I’m behind my car payment due to not working and having no income since I went on medical leave Nov. I hope to return to work after port is put in for chemo and receiving first dose of chemo.

– Young Single Mother of a 4 year old