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Friends Like Me Care Package Request Form

Fields marked with an asterisk (*) are required.

Friends Like Me care packages have been carefully produced to address the needs of recipient diagnosed with breast cancer within the last six months. The materials are designed to support the new patient in a timely manner during those critical first few months when she is dealing with her diagnosis and making decisions about treatment options.

  • Please review the eligibility requirements
  • The Friends Like Me care package must be sent directly to the survivor.
  • You may request a Friends Like Me™ care package for yourself.
  • We customize each care package according to the specifics of the recipient's situation.
FlmBoxRequest
Recipient's Information
  1. xxx-xxx-xxxx
  2. mm/dd/yyyy
  3. mm/dd/yyyy
  4. Does the recipient have a partner/caregiver?:
  5. Does the recipient have insurance to cover the cost of treatment and medications?:
  6. Is she currently receiving or does she plan to receive chemotherapy?:
  7. Is she currently receiving or does she plan to receive radiation?:
  8. Is this a recurrence?:
  9. If this is a self-request, would you like the PBCC's patient advocate to call you?*:
  10. Are there young children at home?:
Sender Information
  1. xxx-xxx-xxxx
  2. mm/dd/yyyy
  3. Are you a breast cancer survivor?:
  4. Would you like to receive emails from the PA Breast Cancer Coalition?*:
  5. Would you like to receive mail from the PA Breast Cancer Coalition?*:
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