CholangioConnect Caregiver Mentor Request Form

Mentor Request for Caregivers

Are you the caregiver of a cholangiocarcinoma (CCA) patient?(Required)

Yes

Name(Required)

First Last

Date of Birth(Required)

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

Other

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Cell Phone Number

Best Time to Call

Morning

Afternoon

Evening

Email(Required)

Enter Email Confirm Email

Preferred method of contact

Preferred Language(Required)

Other Languages Spoken

English

Spanish

French

American Sign Language

Other

Your support system(Required)

Spouse/significant other

Friends

Children

Siblings

Parents

Faith

Other

Name of Patient

First Last

Your relationship with the patient(Required)

Spouse/Significant Other

Parent

Child

Sibling

Other family member

Friend

Other

The patient's age range(Required)

The patient's gender(Required)

Male

Female

Non-binary

Not listed

Prefer not to answer

Patient's Type of Cancer(Required)

Intrahepatic Cholangiocarcinoma

Perihilar Cholangiocarcinoma

Distal Extrahepatic

Mixed HCC/Intrahepatic Cholangiocarcinoma

Not Sure

Other

Patient's stage of cancer(Required)

Patient's date of Diagnosis(Required)

Where is/was the patient being treated?

Did the patient have biomarker testing?(Required)

Yes, and I have the results

Yes, but I do not have the results yet

I don’t know

Which treatment options did the patient receive or is planning to receive? Check all that apply(Required)

Do the patient have minor children?(Required)

Yes

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 factors

How did you learn about the CholangioConnect program?(Required)

Other sources