Woman to Woman Mentor Application

I appreciate your interest in Woman to Woman (W2W), a partnership program between the Ovarian Cancer Research Alliance and Sue's Gift. We are thrilled by your desire to offer peer mentorship and support to newly diagnosed women who are receiving treatment for gynecologic cancer.

Our W2W training will either be in person or via Zoom. Once you've completed the initial training, you're eligible to participate in our monthly Mentor Meetings, including ongoing training and peer support from other mentors and survivors.

Please note mentor eligibility criteria: 1) Gynecologic cancer diagnosis or previvor diagnosis; 2) One-year post-treatment

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

Previvor

Uterine

Vaginal

Vulvar

Please list cell type, if you know it:

Please state the "grade," if you have that information:

Physician

Treatment Facility

What treatment did you receive?

Brachytherapy

Chemotherapy

CyberKnife

PARP inhibitor

Surgery

Radiation Therapy

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

Approximate dates of chemotherapy (if applicable)

What chemotherapy drugs did you receive?

Approximate date of radiation therapy (if applicable)

If you've had a recurrence, please list the date(s) and treatment received:

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

Additional information to assist with facilitating the best match:

Are you bilingual?

Yes

Which languages do you speak fluently?

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 were your greatest challenges following your diagnosis?

What challenges do you currently have?

What coping strategies have you found most beneficial?

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

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.