Mentor Application Intake Form

Thank you for your interest in becoming a mentor. We’re grateful that you’re willing to share your time, experience, and compassion with someone navigating a stomach cancer journey. This form helps us learn more about you so we can make thoughtful matches. After we review your responses, we’ll send a separate mentor agreement outlining the role. If you don’t hear back within five days, please email programs@debbiesdream.org. Please note everything on this form is confidential to the mentorship program and will not be shared outside of this organization.

Mentorship Role

I want to be a mentor for (check all that apply) *

Patient
Caregiver/family member
Male Mentee only
Female Mentee only
Matterhorn Patient

I am a *

Stage and Diagnosis

Please let us know the stage / diagnosis connected to your experience

Stage

Date of Diagnosis

// (mm/dd/yyyy)

Type of cancer

Cancer type (if known)

Adenocarcinoma
Signet Ring Carcinoma
Adenocarcinoma with Signet Ring Cell Features
Diffuse-type
Intestinal-type
Lymphoma
Sarcoma
Other

Please explain if other

Treatment center(s)

Mentor Information

First Name *

Last Name *

Email *

Address 1 *

Address 2

City *

State *

Country *

Zip *

Phone *

Best ways to be in contact with my mentee *

Phone
Email
What's App
Facetime/other video calling
Text

How did you hear about the mentorship program?

Advocacy Day
Word of mouth
Doctor's office
Community Event
DDF Newsletter/Email
DDF Podcast
Facebook
Reddit
Smart Patients
Inspire Community
Triage Cancer Conference
Google / Bing Search
Other

If not listed, how did you learn about us?

Primary Language *

If other, please list

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Mentor Application Intake Form

Mentorship Role

Stage and Diagnosis

Mentor Information