NEW Mentor Request Form rev. 2026

Peer Mentor Request Intake Form

Thank you for taking the time to fill out this form. No one should face stomach cancer alone. Our Peer Mentor Program connects patients, caregivers, and loved ones with someone who truly understands. Please answer each question to the best of your ability so we can make the most thoughtful match possible. All information you share is confidential within the mentorship program and will not be shared outside of our organization. If you do not hear back within 5 business days, please email programs@debbiesdream.org.

Your Role: *

Please specify if applicable

First Name *

Last Name *

Primary Language *

If other, please specify

Matching Preferences

I am seeking a mentor for:

Myself

Someone else

If someone else, please specify:

How do you prefer to be matched? Please check all that apply. (We will do our best to give you the best match possible) *

Same stage

Similar treatments (chemo, immunotherapy, etc.)

HIPEC or PIPAC experience

Total or partial gastrectomy

Chemotherapy after surgery

MATTERHORN trial experience

Zolbetuximab (CLDN18.2) trial experience

Other clinical trial experience

Female mentor

Male mentor

Diagnosis and Staging

Diagnosis *

Date of Diagnosis *

Staging *

Cancer type, if known. (check all that apply)

Adenocarcinoma

Signet Ring Carcinoma

Adenocarcinoma with Signet Ring Cell Features

Diffuse-type

Intestinal-type

Lymphoma

Sarcoma

Other

Please explain if other

Contact

When do you want to be contacted: *

Please contact me ASAP

Please connect with me, but I may take my time to respond

I am not ready to talk yet, but I would still like to be connected to DDF in the interim

Mentorship Program Contact Preference: (Please check all that apply) *

Text

Phone call

Video Call

Other Information

Feel free to add any other criteria/information to help with matching

How You Found Us

How did you find out about our mentorship program? Please check all that apply.

Word of mouth

DDF Newsletter/Email

DDF Podcast

Facebook

Smart Patients

Inspire Community

Other

Triage Cancer Conference

Community event

Google / Bing search

Doctor’s office

If not listed, please explain

If applicable, please let us know who referred you (name of person, name of community event)

Tell us more about who is seeking a mentor (you, a loved one, or both). This could be about your hobbies, favorite sports team, favorite food, etc.

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

About the Person Seeking Support

Please tell us about the person who needs a mentor. All information is confidential to the mentorship program

First Name *

Last Name *

Email *

Address 1 *

Address 2

City *

State *

Country *

Zip *

Phone *

Age: *

Preferred Pronouns

Treating physician/center

Genetic Testing

Please let us know any POSITIVE genetic results (note that biomarkers will be addressed)

Just diagnosed; not tested yet

Waiting for results

BRCA1

BRCA 2

CDH1 Hereditary

CDH1 Variant

CTNNA1

Lynch Syndrome

Other not listed

N/A

VUS of BRCA, CDH1, CTNNA1

If genetic result not listed, please explain

Have any family members been diagnosed with stomach cancer? Check all that apply.

No- Just me (or loved one)

Grandparent

Parent

Sibling

Child

Aunt

Uncle

Cousin

If you have been diagnosed with another cancer, please list here

If family members have had another type of cancer, please list here

Treatment

Please share with us your/your loved one's treatment plan

CHEMOTHERAPY: Please check all that apply

No Chemotherapy

Just diagnosed, waiting on chemo plan

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

Docetaxel single agent

Paclitaxel alone or with Ramucirumab

For chemotherapy not listed, please specify:

IMMUNOTHERAPY (IO): Please check all that apply

Not eligible at this time

Nivolumab (Opdivo)

Pembrolizumab (Keytruda)

Durvalumab (Imfinzi)

Dostarlimab (Jemperli)

Atezolizumab (Tecentriq)

Other

Unknown

No immunotherapy

If other IO, please specify:

Biomarkers and Targeted Therapy

Were biomarkers tested?

If yes, please check off all biomarkers listed in pathology report

MET Amplification

EGFR Amplification

ERBB2 Mutation

FGFR2 Amplification

KRAS Amplification

CDK6 or CCND1 Amplification

ATM Mutation

Waiting for results

CLDN18.2

ERBB2 / HER2 Amplification

MSI‑H / dMMR

PD‑L1

EBV (Epstein–Barr Virus)

Other biomarker not listed

Never knew about this; want to learn more

List other biomarker if applicable

Current targeted therapy:

Trastuzumab (Herceptin; HER2‑targeted)

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

Ramucirumab (Cyramza; VEGFR2‑targeted)

Trastuzumab deruxtecan (Enhertu; HER2‑ADC)

Other

Unknown

No targeted therapy

If targeted therapy not listed, please specify:

Surgery and Local Therapies/Procedures

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

Surgeries

Just diagnosed, unsure of plan

Surgery is scheduled

Total Gastrectomy

Partial Gastrectomy

Surgery is not recommended at this time

Local therapies

HIPEC (Hyperthermic Intraperitoneal Chemotherapy)

PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy)

Cytoreductive surgery

Radiation therapy

Other 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

Local therapy is not recommended for me

Other

If other surgery/procedure/local therapy not listed, please specify:

Clinical Trials

Please let us know which clinical trials have been part of the care journey, IF applicable

Immunotherapy+ Chemo Trials (Non HER2)

Durvalumab + FLOT (MATTERHORN / D‑FLOT)

Pembrolizumab + Chemotherapy (KEYNOTE‑859)

Nivolumab + Chemotherapy (INGA)

ONO‑4578 + Opdivo + Chemotherapy (Phase 2)

HER 2 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)

CLDN18.2 Targeted Trials

Zolbetuximab + Chemotherapy (SPOTLIGHT)

Zolbetuximab + Chemotherapy (GLOW)

Zolbetuximab + Pembrolizumab + Chemotherapy (LUCERNA)

If Yes- Other

Deruxtecan GI Basket Trials

If the patient has tried a trial not listed, please write here

Information Requested

What DDF Programs might interest you? Please check all that apply.

Support Groups

Town Halls with Oncologists

Webinars

Symposia

Community Events

Cooking Demos

Podcasts

What do you have questions about? Please check all that apply.

Understanding my diagnosis

Understanding pathology or biomarker results

Treatment options

Side effects or symptom management

Nutrition during treatment

Getting a second opinion

Navigating my care team

Preparing for appointments

Support resources

Caregiver support

Coping and emotional support

Palliative care

Quality of life support

Other

Insurance or financial navigation

Other Information Requested or let us know anything else the form didn't cover

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