Request a Mentor

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Request a Cancer Mentor

First Name

Last Name

Are you the cancer patient?

Relationship to Patient

Phone Number

Location:

City/Town

State/Country/Province

Time Zone

How did you hear about/were referred to us?

Additional referral details

At what cancer center/hospital(s) are you being treated?

Best ways to reach me

Best Contact Time

Birthdate/Current Age

Preferred Language(s)

Ethnicity

How did you hear about/were referred to us?

Gender Identity

Cancer Experience Details

Cancer Diagnosis

Stage

What type of emotional support do you currently have? (spouse/family, friends, groups, counselor, etc.)

Is there anything else that would help us understand your concerns and who may be the best match for you?

Life Circumstances

Relationship to person diagnosed

From 1 to 10, with 1 being no distress & 10 being extreme distress, what is your distress level today:

What cancer were you diagnosed with and when?

Are you currently undergoing treatment? If so, what treatments are you undergoing?

What cancer center are/were you being treated at?

Tell us more about yourself.