Provider Referral Form

Refer your patients and caregivers with confidence.

CHN offers free, confidential, and professionally led peer support, ensuring personalized matches and providing additional resources when needed to complement your care.

After you submit this form on behalf of your patient or caregiver, a member of our team will reach out to them directly to complete a brief intake call and begin the matching process.

Provider's Information

Referrer's Name and Title *

Referring Organization

Email Address *

Phone Number

Did your patient provide consent for Cancer Hope Network to contact them directly to complete this support request? *

Communication may include email, phone calls, or other agreed-upon methods.

Support Seeker's Information

First Name *

Last Name *

Phone *

Phone Type

Location *

Cancer Hope Network is committed to upholding to your privacy and will never share your personal information.

Time Zone *

Birthdate/Current Age

Ethnicity

Gender Identity

Cancer Experience Details

Cancer Patient's Diagnosis *

What type of emotional support does the Support Seeker currently have?

Is there anything else that would help us understand your Support Seeker's concerns?

Cancer Hope Network will work to connect your support seeker with a trained Peer Mentor who has gone through a similar experience. Additional details about their current situation will be helpful as we work to make that match.

Is your Support Seeker struggling with any of the below life circumstances?

Please select all that apply. This additional information is helpful to our team as we work to find the best match.