Share your stories (The Brave Company)

1

Hi! Let’s get to know you more. What’s your name?* This field is required.

First Name

Last Name

3

What type of cancer, subtype & stage were you diagnosed with?* This field is required.

4

How old were you at diagnosis and what was the date?* This field is required.

Date

5

Please list in order the treatment (including type) you underwent:* This field is required.

Chemotherapy

Radiation

Surgery

Hormone therapy

Any transplants

Others, please specify

6

Please list the treatment (including type) you underwent:

7

What was the result after all of your treatment?* This field is required.

Remission after 1st line treatment

Relapse/ Recurrence (responded to treatment but came back)

Refractory (did not respond to 1st treatment)

Second cancer (different than the first)

Remission after 2nd line treatment

Maintenance/ongoing treatment indefinitely

None of the above

8

What topics (no limit) are you most passionate about and looking forward to discussing specifically in your interview? * This field is required.Examples: mental health, self-advocacy, survivorship, hair loss, identity etc.

9

Which country do you live in?* This field is required.

Country

10

Thank you for your time. Please enter your email address to complete this form. * This field is required.

example@example.com