Questions for Newly Diagnosed Patients
Upon submitting your information, you will see a confirmation message which means we have received your information. A mentor or member of OCRA's staff will be in touch with you soon. Please contact womantowoman@ocrahope.org with any questions.
First Name*
Last Name*
Email*
Phone*
Street Address 1*
City*
State*
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AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Connecticut
Waikato
Singapore
BC
Osun
Copenhagen
QC
AE
NB
AB
ON
CO.LIMERICK
Pa
Auckland
Western Australia
Victoria
Georgia
Pieria
East Sussex
Madrid
QLD
NEW JERSEY
New Jersey
Texas
Mississippi
Ms
35
miss
ms
Zip Code*
Country
About You
As we want to pair our program participants with mentors with similar life experiences to the greatest extent possible, please answer the following questions:
Date of Birth
Marital Status
Single
Married
Divorced
Widow
Sexual Orientation
Do you have children?
Yes
No
Age(s) of children
Language(s) spoken
Religion
Race/Ethnicity
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Ashkenazi Jew
Other
Prefer not to answer
Not Spanish/Hispanic/Latino Origin
Unknown
How would you like a Woman to Woman mentor to contact you?*
Tell us about your "real" life*
Are there specific issues you'd like to talk about or not talk about? If so, please explain. *
Please list the top factors you'd like us to consider when choosing a mentor to match you with*
Is there anything else we should know that will help us make a good match? *
Your Story
Type of cancer*
Date of diagnosis*
Cancer stage at diagnosis*
Age at diagnosis*
Hospital/Medical center where you are being treated*
Please tell us about your cancer journey so far. Include information about your disease, treatment, side effects, where you were in your life when diagnosed and where you are now.*
Are you using any other practices/therapies to help you cope?*
General Inquiries
How did you hear about Woman to Woman?
Would you like to receive patient materials at the address provided? *
Yes
No
By submitting this survey you agree to keep confidential all personal information obtained while participating in Woman to Woman*
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