Self-Request Form

Friends Like Me Care Package Self-Request Form

Fields marked with an asterisk (*) are required.

Friends Like Me^TM care packages have been carefully customized to address the needs of Pennsylvanians diagnosed with breast cancer within the last six months. The materials are designed to support the patient in a timely manner during those critical first few months when she/he is dealing with a new diagnosis and making decisions about treatment options. Please review eligibility requirements:

• The Friends Like Me^TM care package must be sent directly to the patient.
• The recipient must live in Pennsylvania.
• If you are requesting this care package for a loved one, please use the form found opens in a new windowhere.
• If you have been diagnosed with Stage IV metastatic breast cancer, please select “Stage IV metastatic” from the “Breast cancer stage” options.