CholangioConnect Patient Mentor Request

Mentor Request for Patient

Are you the patient?(Required)

Yes

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Transgender male

Transgender female

Gender variant/non-conforming

Not listed

Prefer not to answer

Ethnicity(Required)

Hispanic

Not Hispanic

Race(Required)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Some other race

Prefer not to answer

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Cell Phone Number

Best Time to Call

Morning

Afternoon

Evening

Email(Required)

Enter Email Confirm Email

Preferred method of contact

Preferred Language(Required)

Other Languages Spoken

English

Spanish

French

American Sign Language

Other

Your support system(Required)

Spouse/significant other

Friends

Children

Siblings

Parents

Faith

Other

Type of Cancer(Required)

Intrahepatic Cholangiocarcinoma

Perihilar Cholangiocarcinoma

Distal Extrahepatic

Mixed HCC/Intrahepatic Cholangiocarcinoma

Not Sure

Other

Stage of cancer(Required)

Date of Diagnosis(Required)

Where are you currently being treated?

Where have you previously been treated? (if applicable)

Did you have biomarker testing?(Required)

Yes, and I have the results

Yes, but I do not have the results yet

Biomarkers

Which treatment options have you received or you are planning to receive? Check all that apply(Required)

Do you have minor children?(Required)

Yes

Please state any particular issues you would like to discuss with your mentor.

The following is a list of factors or similarities that may be important to you in being matched with a mentor. Please check all that are important to you.

Gender

Race/Ethnicity

Age

Type of CCA

Geographical location

Stage of disease

Biomarkers/mutations

Type of treatment

Other (Please specify)

Please note that we may not be able to meet all of the desired similarities.

How did you learn about the CholangioConnect program?(Required)