Peer Support Patient Form

The new year is almost here! Please remember to update your insurance with us.
We need a copy of your card every year, even if nothing has changed.

Please fill out the form below to request a Peer Support Mentor.

There was a problem with your submission. Please correct the issues below

About You

First Name*

Last Name*

Preferred Name

Date of Birth*

Gender*

Female Male Non-Binary Other

Best Phone Number*

Best Time to Call*

If "Other," please specify:

Patient Diagnosis & Treatment

Diagnosis*

Date of Diagnosis

Treatments that you have or are currently receiving for your cancer (select all that apply)*

Chemotherapy Clinical Trial Hormone Therapy Immunotherapy Radiation Reconstruction Surgery Transplant Watchful Waiting

Other Relevant Disease & Treatment Information*

Hobbies/Interests*

What do you hope to get out of a mentor/peer relationship?

Please indicate your preference in mentor qualities below in order of importance

	1	2	3	4
Age	Age: 1	Age: 2	Age: 3	Age: 4
Diagnosis	Diagnosis: 1	Diagnosis: 2	Diagnosis: 3	Diagnosis: 4
Treatment	Treatment: 1	Treatment: 2	Treatment: 3	Treatment: 4
Gender	Gender: 1	Gender: 2	Gender: 3	Gender: 4

(1 being the most important quality and 4 not as important)

Thank you for getting in touch! Our staff looks forward to contacting you to help connect you with a mentor/peer. You will hear back from us soon.

I certify that the statements made in this application are true, correct, and have been given voluntarily. By signing below, I give consent to New England Cancer Specialists, to store any information I have provided on this application and all information will be maintained confidential and available only to those directly involved with this program.

Applicant Signature*

* Required Fields

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