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402-334-4773
Get To Know Us
Get To Know Us
What is Community Oncology
Choosing Your Provider
Physicians
Advanced Practice Providers
Nurse Case Managers
NCS Timeline
Patients
Patients
Your First Visit to NCS
New Patient Forms
Insurance and Financial Services
Locations
Managing Side Effects
Services
Services
Medical Oncology
Radiation Oncology
Nuclear Oncology
Hematology
Imaging
Occupational Therapy
Nutrition Services
Mental Health
Pharmacy
Genetic Counseling
Clinical Research Trials
Dignicap®
Tumor Profiling
PSMA
Movement for Longevity
Supportive Care Clinic
Resources
Resources
Healthy U
Peer Mentor Program
NCS Focus Magazine
Education
Podcasts
NCS in the News
Support Organizations
NCS Hope Foundation
For Providers
Careers
SEARCH
PEER MENTOR APPLICATION
Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Female
Male
I would prefer my Mentees to be
(Required)
Female
Male
No Preference
Cancer Diagnosis
(Required)
Type of Cancer Treatment Received (Check all that apply):
(Required)
Surgery
Chemotherapy
Immunotherapy
External Beam Radiation
Nuclear Medicine Therapy
Stem Cell Transplant
Hormone Therapy
Treatment Status
(Required)
Completed
Maintenance
My availability is as follows (check all that apply):
(Required)
MON mornings (9am to 12pm)
MON afternoons (12pm to 6pm)
MON evenings (6pm to 9pm)
TUE mornings (9am to 12pm)
TUE afternoons (12pm to 6pm)
TUE evenings (6pm to 9pm)
WED mornings (9am to 12pm)
WED afternoons (12pm to 6pm)
WED evenings (6pm to 9pm)
THU mornings (9am to 12pm)
THU afternoons (12pm to 6pm)
THU evenings (6pm to 9pm)
FRI mornings (9am to 12pm)
FRI afternoons (12pm to 6pm)
FRI evenings (6pm to 9pm)
SAT mornings (9am to 12pm)
SAT afternoons (12pm to 6pm)
SAT evenings (6pm to 9pm)
SUN mornings (9am to 12pm)
SUN afternoons (12pm to 6pm)
SUN evenings (6pm to 9pm)
Preferred method of communication (check all that apply):
(Required)
Phone
Text
Email
Special Considerations (check all that apply):
I am a parent of children living within the home
I am a parent of adult children
I do not have children
I worked through treatment
I am a retired person and did not work through treatment
I went through treatment with a limited support system
I experienced what I considered significant side-effects of treatment
I was told my cancer diagnosis was rare
Other
Please give more details
NCS Connects Participant Consent
Email
(Required)
Home Phone
Cell Phone
(Required)
Consent
(Required)
I agree to:
I understand that I will serve as a Mentor for a cancer patient paired with me based upon several similarities such as cancer diagnosis, treatment type and treatment stage.
I understand that my participation in NCS Peer Support Program is voluntary.
I understand that my participation in NCS Peer Support Program is as a layperson who cannot give medical, psychological, or legal advice.
I understand that information shared by a Mentor or Mentee is confidential and this confidentiality may be broken if there is concern of physical, psychological, emotional, or financial abuse or neglect to either party or an outside person identified as at-risk by the Mentor/Mentee.
I understand that my Mentee will be asked to maintain confidentiality of information I choose to share with him or her, but Nebraska Cancer Specialists is not liable for any breach of confidentiality.
I agree to provide feedback to NCS staff as collaboration for the NCS Peer Support Program development.
I agree to complete a brief survey after the first contact with each Mentee to whom I am paired.
I understand that I will be paired with one Mentee at a time.
I understand the contact with my Mentee will either be over phone or email, or may be face-to-face in a public setting.
Type your full legal name - This constitutes a digital signature.
(Required)
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