Back to One-to-One Metastatic Breast Cancer Support Pilot Home All services One-to-One Metastatic Breast Cancer Support Pilot Register for One-to-One Metastatic Breast Cancer Support 1 Page 1 2 Page 2 3 Page 3 Form intro We're Breast Cancer Now, the UK's leading breast cancer charity. We provide a wide range of free support services to anyone affected by breast cancer. We're running a small, 6-month pilot of a new service for people living with metastatic breast cancer who aren't currently using our other services. It's a one-to-one peer support service, giving you the chance to speak to a volunteer who also has a metastatic diagnosis. The details you share helps us to learn about you and pair you with one of our trained volunteers. They'll have access to some of these details to help them support you on your calls, and your phone number so the can call you. We'll also use your details to contact you during the pilot appropriately and to measure the pilot's performance. If you're interested in taking part, please fill in the form below. Confirmation I understand and confirm that in providing information about myself including health information and submitting this form, I give Breast Cancer Now my permission to store and use the information I provide for the above purposes. Consent I consent to Breast Cancer Now sharing my information with my volunteer for so they can contact me and provide me with peer support during our calls together Withdraw permission If, after completing this form you no longer want us to use your information in the ways outlined, please contact metastatic121@breastcancernow.org to discuss withdrawing your permission. Is this service for you? Is this service for you? This service is for people with a diagnosis of metastatic breast cancer. Metastatic breast cancer is breast cancer that has spread beyond the breast and lymph nodes under the arm, to other parts of the body like the bones, lungs, liver or brain. You may also hear it being described as secondary or secondaries, metastases, advanced breast cancer or stage 4 breast cancer. Do you have metastatic breast cancer Yes No Sorry Sorry - this service is only available for people living with metastatic breast cancer. See our other services to find the right support for you. Date of metastatic diagnosis Month Month January February March April May June July August September October November December Year Year 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 2074 2075 2076 2077 2078 2079 2080 2081 2082 2083 2084 2085 2086 2087 2088 2089 2090 2091 2092 2093 2094 2095 2096 2097 2098 2099 2100 2101 2102 2103 2104 2105 2106 2107 2108 2109 2110 2111 2112 2113 2114 2115 2116 2117 2118 2119 2120 2121 2122 2123 2124 2125 2126 Where has your breast cancer spread to? For this pilot, we’d really like to support people who aren’t attending our Living with Secondary Breast Cancer in-person or online groups. Have you ever attended our in-person or online groups? Yes No If yes, please select which of the below best applies to you: I’ve attended a group but it wasn’t for me I can no longer attend groups e.g. work, travel etc Other Other Add your reason here Next
