Request a Coach

Personal Information

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Your The patient's biologically assigned gender * Male Female

Contact Methods

Your Patient's Phone number * (###-###-####)

Your Patient's Email Address *

Residential Address

Street address *

City *

State/Province *

Zip code *

Treatment Information

Answering these questions will enable us to place you most effectively with a coach that has had similar experiences to yours.

What is the name of your physician? *

Where is the site of concern? *

Stage/grade of cancer * I II III IV Not staged/Unknown

Year of your patient's diagnosis *

What types of treatment have you has the patient received as part of your their care? * Chemotherapy Radiation therapy Integrative therapy Immunotherapy Radiation Surgery Transplant Other

What other treatment was involved? *

Additional Information

What support are you looking for in a Cancer Coach?

What is the biggest challenge you’re facing right now?

What does your current support system look like?

What would you like us to know about you?

Career, hobbies, children/grandchildren, family, pets, faith, etc.

Is there anything else you would like us to know while reviewing your application?

How did you hear about Roswell Park? *

Please explain *

By checking this box to apply to be a participant in the Roswell Park Comprehensive Cancer Center’s Cancer Coach program, you acknowledge giving authorization for the program administrators to share submitted information with your assigned coach and partners of the program to support your needs. *

Yes, I agree