CholangioConnect Patient Mentor Request Are you the patient?(Required) Yes No If you are filling this out on behalf of the patient, please confirm that the patient is interested in having a mentor prior to completing the rest of the application. After confirming the patient's interest, please answer all of the following questions from the perspective of the patient.Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Transgender male Transgender female Gender variant/non-conforming Not listed Prefer not to answer Ethnicity(Required) Hispanic or Latino Not Hispanic or Latino Other 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 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 Country Home Phone NumberCell Phone NumberBest Time to Call Morning Afternoon Evening Email(Required) Enter Email Confirm Email Preferred method of contact Home Phone Cell Phone Text Message Email Other Preferred Language(Required) Other Languages Spoken English Spanish French American Sign Language Other Other Language(s) Spoken Your support system(Required) Spouse/Significant Other Friends Children Siblings Parents Faith Other Other Support System Type of Cancer(Required) Intrahepatic Cholangiocarcinoma Perihilar Cholangiocarcinoma Distal Extrahepatic Mixed HCC/Intrahepatic Cholangiocarcinoma Not sure Other Stage of cancer(Required) I II III IV V Unknown Date of Diagnosis(Required) MM slash DD slash YYYY 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 No Biomarkers ALK ATM ARID1A BRAF BRCA1/2 CDKN2A EGFR FGFR2 HER2/ERBB2 IDH1 IDH2 KRAS MDM2 MET NOTCH1 NRG1 NTRK PI3KCA RET ROS1 High tumor mutational burden Microsatelite instability (MSI) PD-L1 positive Other Other Biomarker Which treatment options have you received or you are planning to receive? Check all that apply.(Required) Chemotherapy Radiation Targeted Treatment Clinical Trial Immunotherapy Surgery Transarterial Chemoembolization (TACE) Transarterial Radioembolization (TARE) Stent Placement IV Nutrition Enteral Nutrition Palliative Therapy Not Sure Others Other Treatment Do you have minor children?(Required) Yes No 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. Other Factor(s) How did you learn about the CholangioConnect program?(Required) Medical professional CCF website Internet search Social media Google ad Patient or caregiver Navigating a CCA Webinar/Workbook Patient Advocate CCF support group Other (Please specify) Other source
