Friends Like Me2 – Request Form

Fields marked with an asterisk (*) are required.

Friends Like Me2 care packages have been carefully produced to address the needs of recipients diagnosed with metastatic or stage IV breast cancer. The materials are designed to support survivors and thrivers facing a metastatic diagnosis.

If you are requesting a Friends Like Me2 care package for a loved one, please use this form. 

Please review the eligibility requirements:

  • The Friends Like Me2 care package must be sent directly to the survivor.
  • You may request a Friends Like Me2 care package for yourself.
  • If you have been diagnosed with metastatic or stage IV breast cancer, please select “yes” under Recipient’s 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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