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SO WE CAN SERVE YOU BETTERPreparatory Questionnaire for ourDiscovery Call
Thank you for taking a few minutes to complete this questionnaire. Your responses will help us understand your organization, what you’re working on, and what you hope to accomplish so we can make the most of our upcoming conversation.
About Your Organization
Organization Name
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Department or Program
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First Name
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Last Name
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Role/Title
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Others who will be participating in the meeting
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About Your Initiative
Please briefly describe the initiative or project you are developing/interested in.
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What prompted your organization to begin this initiative?
What unmet need are you hoping to address?
What stage best describes your project?
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Exploring the idea
Planning
Developing resources
Pilot implementation
Established program
Evaluation and quality improvement
Expansion or scaling
Current Practice
How are conversations about intimacy, sexuality, relationships, and body image currently addressed within your organization?
Which professionals are currently involved in providing this support (mark all that apply)?
Oncology nursing
Medical oncology
Radiation oncology
Social work
Psychology/Psycho-oncology
Pelvic floor therapy
Physiotherapy
Occupational therapy
Palliative care
Survivorship program
Support group facilitators
Primary care
Other (please specify)
What educational resources are currently available for patients or partners?
How are patients referred for additional support when intimacy-related concerns arise?
Opportunities & Challenges
What do you see as your organization’s greatest strengths related to intimacy-informed survivorship care?
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What are the biggest barriers or challenges you currently face?
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Which areas would you most like to strengthen over the next 12 to 24 months?
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Success
If this initiative is highly successful one year from now, what would be different for patients?
What would be different for clinicians or staff?
How do you hope to evaluate the success of your initiative?
Looking Ahead
Are there any services you're already interested in or would like to talk about? (mark all that apply)
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Organizational Assessment
Education & Training
Referral Pathway Mapping
Programs & Curriculum for Patients
Staff Resources & Digital Support
Implementation Support
Not sure yet. I/we'd like help figuring out where to begin.
Other (please specify)
Are there specific topics or questions you would especially like to discuss during our meeting?
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Is there anything else you would like to share before we meet?
Submit
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