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 *

// (mm/dd/yyyy)

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) *

Email
Text
Phone call
WhatsApp
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.

Community event
DDF Newsletter/Email
DDF Podcast
Doctor’s office
Facebook
Google / Bing search
Inspire Community
Reddit
Smart Patients
Triage Cancer Conference
Word of mouth
Other

If not listed, please explain

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