Circle of Hope Participation Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
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When did you receive your LAM diagnosis (approx date is fine):
-
Month
-
Day
Year
Date
What is your current transplant status:
*
Considering transplant
In evaluation
Evaluation completed but not listed
Listed
Post-transplant
Please list your Transplant Center (if applicable):
Please provide your listing date (if applicable):
-
Month
-
Day
Year
Date
How would you prefer your mentor contact you (pick all that apply):
*
Phone
Email
Text message
USPS mail
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At this time, my primary concerns regarding transplant are:
Transplant timing
Choosing a transplant center
Understanding the evaluation/testing process
Talking to my children and other family members about transplant
Caregiver support
Exercise and nutrition
Hospital stay
Transitioning to home
Restrictions after transplant
Transplant medications
Anxiety and/or stress
Talking to my doctor(s)
Other
I would like to have a mentor because:
From my involvement in the Circle of Hope Transplant Support Program, I hope to gain:
It is important to me that my mentor:
Submit
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