Woman to Woman Peer Mentor Application

Today's Date

Demographics/Background

Name(Required)

First Last

D.O.B.(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Phone(Required)

I am a:(Required)

I am

My loved one

Language(s)(Required)

Race/Ethnicity

Religious Affiliation

Marital Status(Required)

Sexual Orientation

Gender Identity

Do you have any children?(Required)

If yes, please specify age(s):(Required)

Are you currently employed?(Required)

If yes, please specify profession/career field:

How do you like to spend your free time?(Required)

Please share any additional information about what your life looks like today:(Required)

Diagnostic History

Patient's Cancer Diagnosis(Required)

Diagnosis Stage(Required)

Patient's Age at Diagnosis(Required)

Date of Diagnosis(Required)

Have you/your loved one experienced a recurrence?(Required)

Treatment History

Which cancer treatment(s) have you/your loved one received?(Required)

Please check all that apply.

Surgery

Chemotherapy

Radiation

Other

Please specify:

Please share more details about your/your loved one’s treatment history:(Required)

For example, treatment regimens/drugs, duration, side effects, complications, etc.

How long have you/your loved one been off treatment?(Required)

Cancer Treatment Center(Required)

Primary Treating Physician(Required)

W2W Mentorship

How would you be willing to connect with your W2W Mentee?(Required)

Please check all that apply.

Phone Call

Video Call

Email/Text Message

Face-to-Face

When communicating with your Mentee, are there any specific issues that you feel comfortable discussing and/or any topics that you would prefer to avoid? If so, please specify below:(Required)

Is there anything else you would like to share with us that might help us match you with someone seeking support?(Required)

For Patients

Research

Advocacy

How to Help

Woman to Woman Peer Mentor Application

Demographics/Background

Diagnostic History

Treatment History

W2W Mentorship