Woman to Woman Patient Application

Thank you for your interest in Woman to Woman (W2W), a partnership program between the Ovarian Cancer Research Alliance, Sue's Gift and your medical team. The Woman to Woman program matches women with a gynecologic cancer diagnosis with someone who has completed treatment. The knowledge and insight of a survivor who had the same diagnosis and similar experience can alleviate feelings of isolation and the unknown.

To facilitate the best possible match, please complete the following information. We will be in touch with you once we receive this form to set up a brief 1:1 program overview prior to matching you with a survivor.

Date

(mm/dd/yyyy)

Demographic Information

Name

First Name

Last Name

Verify Email

Confirm Email

Verify Email

Phone

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

How do you prefer to communicate? Check all that apply.

Phone

Text

Medical Information

Date of Diagnosis:

Type of Gynecologic Cancer

Cervical

Endometrial

Fallopian

Ovarian

Peritoneal

Uterine

Vaginal

Vulvar

Physician

Treatment Facility

Are you currently in treatment?

Yes

What treatment are you receiving or did you receive?

Surgery

Chemotherapy

Radiation Therapy

What was the date of your surgery? (if applicable)

Approximate dates of chemotherapy (if applicable)

What chemotherapy drugs are you receiving?

Approximate date of radiation therapy (if applicable)

Please provide any other medical details that you feel are relevant.

Additional information to assist with facilitating the best match:

Date of Birth

(mm/dd/yyyy)

Current age

Age of the time of diagnosis

Describe your support system

In general terms, what family members are present in the home?

Are you currently employed?

Yes

If you have worked outside the home, what type of work represents your work history?

What are your greatest challenges at this time?

Is there anything else you would like to share about yourself that might help us with your match?

Request for Information:

Are you interested in receiving information about any of the following Patient Services?

Caregiver Support

Financial Assistance

Lunch 'N Learn Discussion Group

Virtual Integrative Therapy Classes

Website Blogs

How did you hear about the Woman to Woman program?

Confidentiality Agreement

To ensure privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) and to provide indivicuals with control over what personal information is used and disclosed, I agree to provide the above information to Sue's Gift.

Questions?

Please contact Sherry Martin, LCSW, Patient Services Director, at 719-422-9964 or sherry@suesgift.org.

Healthcare Referral

If you are a healthcare professional submitting this information on behalf of a patient, please complete the following:

Healthcare provider name and credentials

Healthcare provider organization

Healthcare provider email

Healthcare provider phone

Healthcare provider comments