Peer to Peer Mentors

Contact Information:
Name*

First NameLast Name
E-mail*
example@example.com
Street Address*
City*
State*
Zip Code*
Cell Phone*
Please reach me by:*

PhoneEmailText Message
Breast Cancer Information
Date of Birth*

MonthDayYear
Date of Diagnosis*

MonthDayYear
Age(s) at Diagnosis*
(if applicable)
Age of Children at Diagnosis
(if applicable)
Description of Breast Cancer Diagnosis
Stage (please check all that apply):*

Previvor0/DCIS or LCIS12A2B3A3B3C4 Metastatic
If your cancer is metastatic, please indicate affected areas*
Hormonal Receptor Description (please check all that apply):*

ER+ER-PR+PR-HER2+HER2-
Genetic Mutation:*

YesNo
If yes (please check all that apply):*

BRCA1BRCA2Other (please specify)
Menopause Stage at Diagnosis:*

PremenopausalPostmenopausal
Multiple Diagnoses:*

Spread to Lymph NodesLymphedemaBreast Cancer RecurrenceNoneOther
Breast Cancer Recurrence:

LocalDistantOther
Location of Distant Recurrence: blank
Surgery Information:*

LumpectomySingle MastectomyDouble MastectomyLymphadenectomyProphylactic SurgeryNoneOther
Reconstruction:*

YesNo
Type of Reconstruction:*

ImplantsFlapHybridNippleOther
Treatment Information:*

ChemotherapyCold Cap TherapyHormonal Therapy/Aromatase InhibitorsImmunotherapyRadiationOther
Please tell us which parameters are most important to you for pairing purposes:*

DiagnosisGeneticsSurgerySurvivorshipAgeSmall ChildrenTreatmentOther
Are you fluent in other languages? If so, which ones?
Please provide any other information about yourself that you think may be helpful in pairing you with a new warrior:
Should be Empty:

Contact Information:

Breast Cancer Information