Request a CholangioConnect Mentor Thank you for your interest in CholangioConnect. Please take a moment to answer the following questions so that we can match you with a CholangioConnect Mentor with a similar profile.Are you a Caregiver Patient Your Name* First Last Relationship to PatientSpouseSiblingDescendant (child or grandchild of patient)FriendOtherName of Patient* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Home Phone NumberWork Phone NumberCell Phone NumberBest time to call Email* Enter Email Confirm Email Preferred Method of Contact*No PreferenceHome PhoneWork PhoneCell PhoneEmailAge Range (of the person requesting a mentor)* Younger than 20 20-29 30-39 40-49 50-59 60-69 Older than 70 Gender* Male Female Type of cancer*Please selectIntrahepatic CholangiocarcinomaDistal CholangiocarcinomaPerihilar (Hilar) CholangiocarcinomaMixed HCC/Intrahepatic CCAI don't knowIntrahepatic Cholangiocarcinoma Intrahepatic CCA occurs inside the liver where cancer develops in the hepatic bile ducts or the smaller intrahepatic biliary ducts. In some cases, patients express a combined diagnosis. Perihilar (Hilar or Klatskin Tumor) Cholangiocarcinoma These cancers develop where the right and left hepatic ducts have joined and are leaving the liver. These are the most common type of cholangiocarcinoma accounting for more than half of all bile duct cancers. Distal Cholangiocarcinoma Distal CCA occurs outside the liver after the right and left hepatic bile ducts have joined to form the common bile duct. This type of cancer is found where the common bile duct passes through the pancreas and into the small intestine. Extrahepatic Cholangiocarcinoma Because perihilar and distal bile duct cancers start outside the liver, they are often grouped together and referred to as extrahepatic cholangiocarcinoma.Stage of Cancer*Please selectIIIIIIIVI don't knowBased on the definitions of staging, located here, please select which stage you fit the mostTumor Information Tumor was or is able to be surgically removed Tumor was or is not able to be surgically removed Tumors located inside the liver only Tumors have spread outside the liver to distant organs such as lungs, bones, peritoneum Recent diagnosis, testing not complete Diagnosis Date(if unknown, leave blank) MM slash DD slash YYYY Where are you currently being treated?Hospital/Cancer Center Has the patient had biomarker testing? Yes No Unknown Also known as molecular profiling, genomic testing, tumor testing, or Next Generation Sequencing "NGS") To learn more, click here.If yes, please list biomarker/mutations: ALK ARID1A BRAF BRCA1/2 CDKN2A EGFR FGFR2 HER2/ERBB2 IDH1 KRAS MET NRG1 NTRK RET ROS1 MSI high PD-L1 positive Other (please specify) Check all that applyOther biomarkers/mutations Which treatment options were you offered?Check ALL that apply. Chemotherapy Clinical Trial Radiation Surgery Transplant Targeted Therapy Immunotherapy Local or Regional Therapy performed by an Interventional Radiologist Other Other treatment option: What kind of chemotherapy? What kind of clinical trial? What kind of radiation? What kind of surgery? Marital StatusSelectMarriedSingleSeparatedSignificant OtherDivorcedWidowedChoose not to answerDo you have children? Yes No How many children under 21 years of age? How many children over 21 years of age? Current employment statusSelectFull-timePart-timeRetiredDisabilityHomemakerUnemployedOtherLanguages spoken English Spanish French Sign Language Other Other language Your support system(check all that apply) Spouse/Significant Other Friends Children Siblings Parents Faith Other Other support How did you find out about Cholangio Connect?SelectMedical ProfessionalCCF WebsiteInternet SearchSocial MediaGoogle AdPatient or CaregiverNewly Diagnosed/New to CCF ProgramOther (comment below)Other, please specify. Are there any particular issues you would like to discuss with your Mentor?* I understand that the information on this form with be shared with a CCF volunteer mentor.
