Radiation?Yes or No?
If yes, Please describe treatment for 1st
episode, followed by treatment for recurrence (if applicable) Example:
First time no radiation. Recurrence 25 treatments.
Stem Cell Transplant?Yes or No:
If yes, please describe:
Bone Marrow Transplant? Yes or No
If yes, please describe:
Alternative Treatments?Please List:
Are you taking (or have you taken in the past) any of the following?
Tamoxifen (Novaledex) or Herceptin or Avista
(Raloxafine) or
Aredia (for osteoporosis prevention) Please list all that apply:
INDICATE AVAILABILITY:
24 Hour Telephone Support Network
Available for Telephone Support?Survivors Only Please
If Yes, tell us exactly when you are available. (List Days/Evenings of
the week/weekend you can be scheduled (example:) I am available Monday,
Wednesday Thursday-days; Tues -Evenings; Saturday-days
Home Visits:
Available for Home Visits?Please let us know if you are not
available at any time
Transportation Services:
Available for Transportation Services?Please let us know whether you are available
for transportation services (own vehicle required) or any times you are NOT available for
transportation services.
Clerical/Office:
Available for Clerical?Please let us know if you are available days, evenings,
weekends or any time
Please note: Volunteers who sign up for in-home visits and/or
transportation services(including companionship during chemotherapy) will be paid $.31 per
mile for travel costs plus parking costs..
Tell us why you wish to become a Breast Friends volunteer?
What words did you hear during your recovery that helped you the most?
How did you cope with your own experience? Did you seek a support network of some kind?
Did it provide what you needed?
Are there any special areas of interest or individual methods you used during your
recovery process that you would like to share with a caller?
Would a family member (husband,teenage/adult child, parent,sibling) be willing to
participate in our peer support program and talk to a caller's family member should they
need support.
Name:Relationship to you:
I acknowledge that as a Breast Friends volunteer I an
only offer peer support, I will not offer medical advice,interpret medical tests or
findings, contradict, disagree or otherwise comment on treatment or recommendations made
by a caller's physician. I will not refer a caller to a physician unless the caller
indicates specifically that she does not have a physician or is requesting a referral for
a second opinion. Nor will I comment or render an opinion about the caller's choice of
physician. Furthermore, I will not use Breast Friends or its callers as a forum to express
political or religious views, endorse a particular medical treatment, product or service
or to conduct business activities or engage in any type of solicitation for my own part.
I acknowledge that my relationship with Breast Friends is strictly
voluntary, and that both parties have the right to terminate said relationship at any time
without cause or prejudice. All information received is kept
strictly confidential and will not be distributed in any way.
By submitting this form, I acknowledge that I have read and
understood the above acknowledgement.