Request Form

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.
  • If you are requesting a Friends Like Me2 care package for someone who has been diagnosed with Metastatic or stage IV Breast Cancer, please select “yes” under Recipients Information.
FlmBoxRequest
Recipient's Information
  4. No PO Box addresses - the PBCC sends out care packages through UPS and must have a street address.
  10. xxx-xxx-xxxx
  11. mm/dd/yyyy
  12. mm/dd/yyyy
  14. Has the recipient been diagnosed with Metastatic or stage IV Breast Cancer?
  16. Does the recipient have a partner/caregiver?
  17. If so, please choose the option that best describes the recipient’s caregiver
  19. Does the recipient have insurance to cover the cost of treatment and medications? ***If you are uninsured or underinsured, request a call with our Patient Advocate who can provide you with resources to help with coverage
  20. Is she currently receiving or does she plan to receive chemotherapy?
  21. Is she currently receiving or does she plan to receive radiation?
  22. Will her treatment require surgery?
  23. Is the recipient sensitive to scented items?
  24. Is this a recurrence?
  25. Are there young children at home?
Sender Information
  10. xxx-xxx-xxxx
  11. mm/dd/yyyy
  12. Are you a breast cancer survivor?
  14. * Would you like to receive emails from the PA Breast Cancer Coalition?
  15. * Would you like to receive mail from the PA Breast Cancer Coalition?
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