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 are requesting a Friends Like Me2 care package for someone who has been diagnosed with Metastatic or stage IV Breast Cancer, please select “yes” when asked if the recipient is facing stage IV breast cancer.