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BCA Peer Mentoring Questionnaire
1.
Would you be interested in volunteering to provide peer mentorship to a breast cancer patient, patient’s spouse or caregiver?
Yes
No
2.
If yes, your preferred method of contact (circle all that apply)
Email
Phone
Text
Skype or Facetime Video
In-person support group
Other (please specify)
3.
If you are a current patient, spouse, or caregiver, would you be interested in receiving peer mentorship from a volunteer?
Yes
No
4.
If yes, your preferred method of contact (circle all that apply)
Email
Phone
Text
Skype/Facetime video
In-person support group
Other (please specify)
5.
Please answer any of the following areas of support that interest you, whether it be as a volunteer or as someone receiving help
Surgical: mastectomy, lumpectomy, reconstruction, going "flat," etc.
Treatment: chemotherapy, radiation, lymphedema, hormone-blocking, holistic, etc.
Fertility: hysterectomy, oophorectomy, chemo-related fertility issues, etc.
Spousal/caregiver support
Male breast cancer
BRCA 1/2 positive
Living with Stage 4 breast cancer
Recurrent disease
Diagnosis under age 40
Talking to kids about diagnosis
Other (please specify)
6.
If you are interested in volunteering, please provide contact information and anything you are willing to share about your experience so we can gauge interest.
Name
Preferred Contact Information
