Auxiliary MentoringTraditional Mentoring Auxiliary Mentoring: Occasional check-ins and messages of encouragement Traditional Mentoring: More consistent check-ins and on-going communication Full Name Email Address Your Address Street Address City State New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home Phone Cell Phone Preferred Contact MethodEmailHome PhoneCell Phone Date of Birth Age Marital Status SingleMarriedDivorcedWidowed Sex MaleFemale Children Please include the number of girls or boys and their age(s) at the time of diagnosis Ethnic Origin African AmericanAsian AmericanCaucasianHispanicNative AmericanOther Relationship to the Patient Patient's Diagnosis Date of Diagnosis Patient's Treatment (If applicable) Please list if the patient has received chemotherapy, radiation, hormonal, or other treatment. Along with the treatment, please tell us the type. Patient's Prognosis What are the greatest challenges you face as a caregiver? Please check your top three choices on how you would like to be connected to a mentor. Patient's DiagnosisPatient's StagePatient's Treatment PlanRaceMarital StatusEmploymentChildrenGenderAge Additional information to help us best facilitate a mentor Referral Source Self-referralHealth Care ProviderRelative / FriendCommunity ReferralMentor VolunteerOther If you selected other, please specify your referral source Confirmation (Please type your name)
