NEW Mentor Intake Form Rev. 2026

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

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

What's App

Facetime/other video calling

Text

How did you hear about the mentorship program?

Advocacy Day

DDF Podcast

Word of mouth

Community Event

DDF Newsletter/Email

Facebook

Smart Patients

Inspire Community

Triage Cancer Conference

Google / Bing Search

Other

Doctor's office

If not listed, how did you learn about us?

Primary Language *

If other, please list

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Matching Information

Please share as much information as you can to help match with a patient or caregiver. All information on this form is confidential to the mentorship program

Genetic Testing

Have you (or the person you cared for) undergone genetic screening for cancer?

If yes, what was the result?

BRCA1

BRCA 2

CDH1 Hereditary

CDH1 Variant

CTNNA1

Lynch Syndrome

Other not listed

N/A

VUS of BRCA, CDH1, CTNNA1

If not listed, please explain

Is there a family history of stomach cancer?

Only me/loved one

Parent

Sibling

Grandparent

Child

Aunt

Uncle

Other

Cousin

If other, please explain

Chemotherapy and Immunotherapy (IO)

Please check all chemo regimens that apply

No Chemotherapy

FOLFOX (5‑FU, Leucovorin, Oxaliplatin)

CAPOX / XELOX (Capecitabine, Oxaliplatin)

FLOT (5‑FU, Leucovorin, Oxaliplatin, Docetaxel)

FOLFIRI (5‑FU, Leucovorin, Irinotecan)

5‑FU (fluorouracil) single agent

Capecitabine (Xeloda) single agent

Irinotecan single agent

Lonsurf (Trifluridine/Tipiracil)

Other

Unknown

Paclitaxel alone or with Ramucirumab

Docetaxel single agent

Please check all IO regimens that apply

Not eligible at this time

Nivolumab (Opdivo)

Pembrolizumab (Keytruda)

Durvalumab (Imfinzi)

Dostarlimab (Jemperli)

Atezolizumab (Tecentriq)

Other

Unknown

No immunotherapy

Biomarkers and Targeted Therapy

Have biomarkers been tested?

If yes...

Please check all that apply.

MET Amplification

EGFR Amplification

ERBB2 Mutation

FGFR2 Amplification

KRAS Amplification

CDK6 or CCND1 Amplification

Waiting for results

CLDN18.2

ERBB2 / HER2 Amplification

MSI‑H / dMMR

PD‑L1

ATM Mutation

EBV (Epstein–Barr Virus)

Other biomarker not listed

Got tested, negative for all

Was not aware; interested in learning more

Please check all targeted therapies that apply

No targeted therapy

Trastuzumab (Herceptin; HER2‑targeted)

Zolbetuximab‑clzb (Vyloy; CLDN18.2‑targeted)

Ramucirumab (Cyramza; VEGFR2‑targeted)

Trastuzumab deruxtecan (Enhertu; HER2‑ADC)

Other

Unknown

Surgery/Procedures/Local Therapies

Please let us know what surgeries, procedures, or local therapies have been part of your (or your loved one’s) care.

Surgery

Surgery is scheduled

Total Gastrectomy

Partial Gastrectomy

Surgery is not recommended for me

Other

Please explain if not listed

Procedures

Feeding tube (G‑tube or J‑tube)

Stent placement (esophageal or gastric outlet)

NG Tube for blockage

Diagnostic laparoscopy

Port placement

PICC Line

Central Venous Catheter

Other

Unknown

None of these

Local Therapies

HIPEC (Hyperthermic Intraperitoneal Chemotherapy)

PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy)

Cytoreductive surgery

Radiation therapy

Please let us know what other surgeries/procedures/therapies not listed

Experience with Clinical Trials

Do you have clinical trial experience?

If yes, please share which clinical trial(s) you or your loved one participated in:

Immunotherapy + Chemotherapy Trials (Non‑HER2)

Durvalumab + FLOT (MATTERHORN / D‑FLOT)

Pembrolizumab + Chemotherapy (KEYNOTE‑859)

Nivolumab + Chemotherapy (INGA)

ONO‑4578 + Opdivo + Chemotherapy (Phase 2)

HER2 Targeted Trials

Zanidatamab + Chemotherapy (HERIZON‑GEA)

Pembrolizumab + Trastuzumab + Chemotherapy (KEYNOTE‑811)

Trastuzumab Deruxtecan / ENHERTU (DESTINY‑Gastric04)

ENHERTU + Chemotherapy + Pembrolizumab (DESTINY‑Gastric05)

Ucatinib (HER2‑Targeted Immunotherapy)

CLDN 18.2 Targeted Trials

Zolbetuximab + Chemotherapy (SPOTLIGHT)

Zolbetuximab + Chemotherapy (GLOW)

Zolbetuximab + Pembrolizumab + Chemotherapy (LUCERNA)

Other

Deruxtecan GI Basket Trials

Other not listed

Topics I feel comfortable supporting

Please check all that apply

Understanding a diagnosis

Understanding pathology or biomarker results

Treatment experiences

Side effects or symptom management

Nutrition during treatment

Getting a second opinion

Navigating a care team

Preparing for appointments

Caregiver support

Coping and emotional support

Grief

Palliative care

Clinical trial experiences

Insurance or financial navigation

Life after cancer/survivorship

Other ways I am happy to support my mentee(s)

Please add anything else you'd like us/your mentee(s) to know

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.