Peer to Peer Mentorship Program

Pink Aid is here to help provide friendship and inspiration through our Warrior's personal experiences. To make the best connection, please provide as much information that you are comfortable with.
How can we support you?*

I am seeking informationI am interested in being matched with a mentor
Please tell us which parameters are most important to you for pairing purposes:*

DiagnosisGeneticsSurgerySurvivorshipAgeSmall ChildrenTreatment
Treatment Information:*

ChemotherapyCold Cap TherapyHormonal TherapyMastectomy/LumpectomyRadiationProphylactic Surgery
Patient Information
Date of Birth*

MonthDayYear
Name*

First NameLast Name
Address
City, State Zip
E-mail*
example@example.com
Phone Number
Date of Diagnosis

MonthDayYear
Breast Cancer Type and Stage:
What is your preferred language?
Additional Information you would like to share with us to help us better understand the support you are seeking:
The best time to reach me:*

9:00 a.m. to 12:00 p.m12:00 p.m. to 1:00 p.m.1:00 p.m. to 5:00 p.m.5:00 p.m. to 8:00 p.m.
Please reach me by:*

PhoneEmailText Message
Referred by:*
Mentor Program Waiver

Pink Aid Mentors offer friendship, inspiration and compassionate support. Mentors are available to listen and to share their own personal breast cancer journeys. The experiences shared by the Mentors are their own and do not represent the view of Pink Aid. Any information provided by the Mentors should not be considered a substitute for advice from a healthcare professional.

Please consult with a physician or other healthcare professional regarding any medical or health related diagnosis or treatment options.
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Pink Aid is here to help provide friendship and inspiration through our Warrior's personal experiences. To make the best connection, please provide as much information that you are comfortable with.

Patient Information