Self-Request Form

Friends Like Me Care Package Self-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 have been diagnosed with Metastatic or stage IV Breast Cancer, please select “yes” under Recipients Information to ensure you receive a Friends Like Me2 care package.
FlmBoxSelfRequest
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
  14. mm/dd/yyyy
  18. Have you been diagnosed with Metastatic or stage IV Breast Cancer?
  20. Do you have a partner/caregiver?
  21. If so, please choose the option that best describes your caregiver
  23. Do you 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
  24. Are you currently receiving or do you plan to receive chemotherapy?
  25. Are you currently receiving or do you plan to receive radiation?
  26. Will your treatment require surgery?
  27. Is this a recurrence?
  28. * Would you like the PBCC's patient advocate to call you?
  29. xxx-xxx-xxxx
  30. Do you have young children at home?
  32. Is the recipient sensitive to scented items?
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