HEADstrong Foundation

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Comfort Kit Requests

Please fill out the form to request a comfort kit be sent out. Our comfort kits are sent out on a weekly basis and include items we have found helpful for those going through cancer treatment. Because of the large number of requests, we are only able to offer 1 kit per patient.

Have you received a comfort kit from HF in the past?

Yes

We Are Sorry But You Do not Qualify

Since you have already received a kit from us, you do not qualify for another kit. We wish you the best as you continue on your fight.

Do you live in the United States

Yes

We Are Sorry But You Do not Qualify

Since you do not live within the United States, you do not qualify for a kit as we are unable to send kits outside of the US. We wish you the best as you continue on your fight.

Are you currently receiving active cancer treatments?

Ex. Chemo, Radiation, Transplant, CAR-T Therapy

Yes

We Are Sorry But You Do not Qualify

Since you are not receiving active treatments, you do not qualify for a kit. We wish you the best as you continue on your fight.

How did you hear of HEADstrong Foundation?

Contact Information

Name

First Name

Last Name

Verify Email

Address

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Phone

Date of Birth

(mm/dd/yyyy)

Type of Cancer

Date of Diagnosis

(mm/dd/yyyy)

Gender

Male

Female

Non-specific

Treating Physician Information

Hospital Where Receiving Treatment

Treating Physician Name

Prefix

First Name

Last Name

Suffix

Physician Address

Address Line 1

Address Line 2

City

State

State/Province

ZIP/Postal Code

Country

Physician Phone #

Are you willing to share your story with us and our supporters?

We love to share patient/caregiver stories with our supporters so we can continue to help as many cancer patients as possible. If you are willing, please email a picture with your new kit, contact info and your story to us at HFsupport@headstrong.org and we will share with our marketing team.

Yes! Absolutely!

No, I am not comfortable with sharing.

Electronic Certification

The undersigned certifies the below

The undersigned certifies to HF that he/she/they meets the eligibility requirements of the Fighter/Relief Program, as described in this Application, and that all the information provide in or with this Application is true and correct.

I agree