Friends
    Like Me
Request Form
Fields marked with an asterisk (*) are required.

Recipient Information:
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.



MyPBCCWhat's This?
Recipient's Information
  10. Occasionally PBCC has a surplus of event tee-shirts. We will send them out when available.
  11. Does the recipient have a partner/caregiver? :
  12. Does the recipient have insurance to cover the cost of treatment and medications? :
  13. Is she currently receiving or does she plan to receive chemotherapy? :
  14. Is she currently receiving or does she plan to receive radiation? :
  15. Is this a recurrence? :
  16. If this is a self-request, would you like the PBCC's patient advocate to call you? :
  17. Are there young children at home? :
Sender Information
  11. Are you a breast cancer survivor? :