Woman to Woman Peer Support Application

If you’d like to talk to someone, and you’re not near one of our hospital or community-based program sites, we can connect you with someone through our national mentoring program. You can request a mentor by email, phone or online—whatever works for you—and we’ll match you with a mentor who’s right for you.

Email: womantowoman@ocrahope.org
Phone: 212-268-1002

Here’s how it works:

Step 1: Fill out the below form, telling us a little about yourself, your medical history, and your preferences. Do you want to talk to a mentor your own age? With your religious background? Knowing this information helps us find the best possible mentor for you to talk to.
Step 2: We match you based on your preferences and availability. If you’d like, we can send helpful informational materials about gynecologic cancers straight to your home too.
Step 3: We will virtually introduce you to your survivor mentor, who is a trained volunteer and a gynecologic cancer survivor, just like you.

Ready to get started? Fill out the below form and we’ll be back in touch. If you do not hear back from a member of the OCRA team within 1 business day, please email womantowoman@ocrahope.org

If you have any questions or concerns about participating in Woman to Woman, please email us at womantowoman@ocrahope.org.

Name*

First Last

Email*

Phone*

Address*

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

I am a:*

I am:*

My loved one:*

Date of Birth*

Marital Status*

Sexual Orientation

Do you have children?*

Age(s) of children

Language(s) spoken*

Religion

Race/Ethnicity

How would you like a Woman to Woman mentor to contact you?*

Tell us about your "real" life*

Are there specific issues you'd like to talk about or not talk about? If so, please explain.

Please list the top factors you'd like us to consider when choosing a mentor to match you with.*

Is there anything else we should know that will help us make a good match?*

Type of cancer*

Date of diagnosis*

Have you/your loved one experienced a recurrence?*

Cancer stage at diagnosis*

Patient's age at diagnosis*

Primary treating hospital/medical center*

Please tell us about your cancer journey thus far, including information such as what led to the diagnosis, experience with treatment, symptoms/side effects/complications, etc.*

Are you using any other practices/therapies to help you cope?*

How did you hear about Woman to Woman?*

Would you like to receive patient materials at the address provided?*

By submitting this survey you agree to keep confidential all personal information obtained while participating in Woman to Woman*