Benefits of Hope - Get Matched Form

You are not alone.

A cancer diagnosis - whether your own or a loved one’s - can be overwhelming. Through our Benefits of Hope partnership, your organization is making it easier to find meaningful support. Cancer Hope Network connects employees with trained Peer Mentors who have faced similar experiences and are here to help.

Complete the form below to begin the process. A member of our team will follow up to learn more about your needs and match you with a peer mentor who truly understands. We're here for you—every step of the way.

Demographic Information

First Name *

Last Name *

Email *

Phone *

Location

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

Time Zone *

Benefits of Hope Partner / Current Employer *

At what cancer center/hospital(s) are you being treated?

Best ways to be reached *

Birthdate/Current Age

Preferred Language(s) *

Ethnicity *

Gender Identity *

Cancer Experience Details

Cancer Diagnosis *

Stage

What type of emotional support do you currently have? (spouse/family, friends, groups, counselor, etc.)

Is there anything else that would help us understand your concerns and who may be the best match for you?

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

Are any of the below life circumstances currently impacting your cancer experience?

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

From 1 to 10, with 1 being no distress & 10 being extreme distress, what is your distress level today: *