Question Title

1. Name (First, Last) (Required.)

Question Title

2. Pronouns (ie: they/she/he/xe) (Required.)

Question Title

3. Street Address (Please include City, State, and Zip Code) (Required.)

Question Title

4. Country (please spell out in full (e.g. "United States of America") (Required.)

Question Title

5. Email Address (Required.)

Question Title

6. Primary Phone Number (Required.)

Question Title

7. Company (if applicable)

Question Title

8. Birth Year

Question Title

9. How do you identify in terms of race/ethnicity? Please select all that apply (Required.)

Question Title

10. How do you identify in terms of gender? (Required.)

Question Title

11. How did you hear about Brushes with Cancer

Question Title

12. If you heard about the program through a friend or family member, please let us know who referred you.

Question Title

13. Have you participated in BWC or attended the celebratory event?

 

Question Title

14. If yes, in what program or what capacity did you participate?

Question Title

15. Important Definitions : At Twist we identify survivors as anyone that has heard those three words "you-have-cancer" as you have survived that life changing experience. It is not about remission, cure, in treatment or out of treatment. Previvors are genetically predisposed to cancer and caregivers are individuals who are primary caregivers to individuals touched by cancer.

How do you identify? (Required.)

Question Title

16. What was the date of diagnosis (es) if relevant?

Question Title

17. What is your disease site? If you are a caregiver, what is the disease site of your loved one? Please check all that apply.

Question Title

18. Do you have inherited cancer susceptibility? If so what kind? Please select all that are relevant.

Question Title

19. If you identify as a caregiver, has your loved one died?

Question Title

20. Where have you or your loved one received medical treatment?

Question Title

21. Please include the names of you or your loved ones medical team (oncologist, surgeon, radiologist, nursing staff, etc.) if you are willing to share that information.

Question Title

22. Why are you interested in participating in the program?

Question Title

23. What is your "twist on cancer?" (Lessons learned and big picture takeaways?) (Required.)

Question Title

24. Are you comfortable sharing your story?

Question Title

25. What is your preferred method of communication?

Question Title

26. I have participated in mental health counseling, psychotherapy, support groups, or other organizations/professional relationships to support me with my diagnosis/caregiving needs.

Question Title

27. If yes, where?

Question Title

28. My support system is mostly made up of: 

Question Title

29. I am in remission.

Question Title

30. My disease is chronic.

Question Title

31. Do you believe your employer would be interested in supporting Brushes with Cancer? If so please provide us with the name and contact information for the person(s) we should be in touch with.

Question Title

32. Brushes with Cancer is currently looking to secure participants in the program. If you would like to nominate a potential candidate as an inspiration, artist or member of our host committee please include their name, email and possible role in the program.

Question Title

33. I understand I am responsible for connecting with my artist a minimum of 6 times over the course of our work together.

Question Title

34. Do you anticipate any barriers to participating in Brushes with Cancer, such as ADA accommodation needs,  financial concerns, language barriers, etc.?

Question Title

35. I feel disconnected from the world around me. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

36. Even around people I know, I don't feel that I really belong. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

37. I feel so distant from people. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

38. I have no sense of togetherness with my peers. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

39. I don't feel related to anyone. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

40. I catch myself losing all sense of connectedness with society. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

41. Even among my friends, there is no sense of brother/sisterhood. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

42. I don't feel that I participate with anyone or any group. (Required.)

Strongly Agree Strongly Disagree
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

43. Do you anticipate undergoing any major life changes or significant stressors which may overlap with the Brushes with Cancer Program timeframe that may or may not impact your participation in the program?

Question Title

44. As part of an ongoing effort to strengthen the impact of our programs, we may collect and analyze participant responses to program applications and evaluations. When analyzing responses, we are interested in trends in our data, rather than the responses of any particular person, and therefore responses will be de-identified for the purpose of data analysis. If you prefer that your responses not be included in data analyses, please check below. Please select Yes if you wish to include your de-identified responses and select No if you wish to not include your responses in future studies.

T