Companion Inquiry Form

Your name*

Phone number*

Email:

Are you looking to talk to someone with

any cancer experience lung cancer specific experience either

Are you looking for someone with

patient/survivor experience caregiver/care-partner experience either

Would you prefer a

male companion female companion either

Your preferred age range for my companion

25-45 46-60 60+ any age

Is there anything else we should know in order to match you to an appropriate companion?

How would you like your conversation(s) to occur?*

text
email
phone call
in person
not sure - need more info