Patient Support Group Registration Form – HEMATOLOGY CANCER CONSORTIUM

HEMATOLOGY CANCER CONSORTIUM

Patient Support Group Registration Form

Patient Support Group Registration Form

Full Name

Email Address

Phone Number

Current Address

Category (Please Select One):

Patient

Caregiver

Survivor

Volunteer

Other: (Please specify)

Other: Category

Areas of Interest (Please select all that apply):

Hematologic malignancy treatments

Nutrition during and after cancer treatment

Mental wellbeing of patients and caregivers during and after treatment

Physical rehabilitation post-treatment

Financial support and resources for treatment

Emotional support and counselling

New treatments and research updates

Long term side effects of cancer treatment

Life expectancy in blood cancers

Life style modifications during and after cancer treatments

Other

Other Areas of Interest

Support Group Preferences:

How frequently would you like to participate in support group meetings?

Weekly

Bi-weekly

Monthly

As needed

What format would you prefer for support group sessions?

In-person

Online

Hybrid (in-person and online)

Would you be open to one-on-one peer support?

Yes

No

Newsletter Subscription:

Would you like to receive mailers on the above topics?

Yes

No

Medical Information (for patients only):

Type of Cancer:

Date of Diagnosis:

Treatment Received (Chemotherapy, Radiation, etc.):

Are you currently undergoing treatment?

Yes

No

Name of the Hospital where treatment received

If You Are a Survivor:

Year of Treatment Completion:

Type of Cancer Treated:

Current Occupation:

Studying

Employed

Self-employed

Homemaker

Other: (Please specify)

Other Occupation:

Caregiver Information (for caregivers only):

Relation to the Patient:

Patient’s Current Condition (if applicable):

How long have you been a caregiver?

What support would you find helpful as a caregiver?

Emotional support

Training in patient care

Financial guidance

Respite services

Other

Other Support