Pink Peers Mentorship

ONE-ON-ONE
WITH A PEER MENTOR

Do you have a new diagnosis? Have you been diagnosed with the breast cancer gene? Are you in active treatment and just want some support? Would you like to be connected with others that have experienced breast cancer?

Pink Peers is our one-on-one mentorship program. It is a fellowship of volunteer breast cancer survivor mentors who are matched with mentees, those with breast cancer who request support.

The Pink Peers are Peer mentors who are trained by a licensed clinical social worker. Each is a survivor of breast cancer, herself. They can listen to you and talk through worries or concerns that you may have. These advocates are here to encourage you along this journey.

More About Pink Peers Mentorship Program

Step 1: Complete the Form Below

Mentees must complete a mentor request form below to request being assigned to a mentor. Pink Lemonade Project staff and our healthcare partners help match each mentee to appropriate mentors.

Information entered below may be shared with a licensed clinical social worker or nurse navigator to help connect you to the best peer mentor. All volunteers agree to keep conversations strictly confidential. In emergency situations, when disclosure is necessary for the life or safety of our clients or another individual, Pink Lemonade Project staff will notify medical professionals and/or authorities. We have mentors who speak English, Spanish, and Ukrainian.

Step 2: Complete the ROI Form

A completed Release of Information (ROI) Form is now required for enrollment in the mentorship program. This form should be completed by the patient or their authorized representative (e.g., Guardian, Executor of Estate, Health Care Power of Attorney).

Complete the ROI Form

Request a Mentor Form

"*" indicates required fields

First Name*

Last Name*

Your Address*

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

County*

Phone*

Email*

Date of Birth*

MM slash DD slash YYYY

Age*

Year of Diagnosis*

Month of Diagnosis*

Please specify details about your breast cancer diagnosis.*

Breast Cancer Stage*

Treatment Description*

Preferred Language*

Gender*

Female

Male

Transgender

Non-binary / non-confirming

Prefer Not to Answer

Our programs are funded by many donors from the community. We must report aggregate data (ex. demographic and geographic) of our participants. The demographic information you provide assists us in attracting more support to continue our programs to serve diverse populations. The information gets totaled and never includes individual’s names or contact information.

Race / Ethnicity*

African American / Black

Asian

White

Hispanic/Latino

American Indian/Alaskan Native

Native Hawaiian/Pacific-Islander

Other

Prefer Not to Answer

If Other, what is Your Race / Ethnicity?

What do you hope to get out of a mentor relationship?*

Mentor Match Preference*

Diagnosis

Treatment

Age

Stage of Life

Preferred Communication

Phone

In Person

What is the best day and time to reach you?*

Please be specific.

Nurse or Social Worker Info

Name of Nurse Navigator or Social Worker*

First Last

Nurse Navigator or Social Worker Email

Nurse Navigator or Social Worker Phone

Nurse Navigator or Social Worker (listed above) works at the following hospital

Are you a healthcare provider filling out this form on your patient's behalf?*

Yes

Check boxes to confirm the patient:

Would like to sign up for general email blasts which include PLP’s monthly program information.

Would like to sign up for email blasts for metastatic breast cancer patients which include quarterly newsletters and information on MBC related events.

Program Expectations & Procedures*

I have read, understand and agree to the expectations & procedures.

This program is specifically designed to provide one to four sessions with a volunteer peer mentor who is a breast cancer survivor or is living with metastatic breast cancer. Following your completion of a Mentor Request form, a Pink Peer mentor will be in contact with you--the mentee--within approximately 7 days. Your peer mentor has been trained by an oncology social worker and can provide basic support to you along your breast cancer journey. They can also inform you of other Pink Lemonade Project programs, other support groups, and any additional local resources available. They do not provide medical advice and they are not a professional mental health provider. When possible, matches will be made between peer mentor and mentee that share similar life situations, age, diagnosis, treatments, family units, etc. Please note- the connections between a peer mentor and mentee are limited to 1-4 sessions and should consist of meaningful interaction[s] without fostering a dependent relationship. Any continued contact must be agreed upon by both parties.

Pink Lemonade Project is interested in expanding the number of mentors that we have. To become a mentor, you must be a breast cancer survivor and have attended one of our retreats or events in the past. In particular we are interested in new mentors who speak Russian or Spanish, or other languages. New mentors are also required to participate in a training by our team of clinical social workers.

Step 1: Submit the Become a Mentor Form Below

Step 2: Complete the ROI Form

Submit a Release of Information (ROI) Form, which is now required for Pink Lemonade programs. This form should be completed by the patient or their authorized representative (e.g., Guardian, Executor of Estate, Health Care Power of Attorney).

Complete the ROI Form

Become a Mentor

"*" indicates required fields

First Name*

Last Name*

Your Address*

Street Address City State ZIP Code

County*

Email*

Phone*

Date of Birth*

Month

Day

Year

Age*

Gender*

Female

Male

Transgender

Non-binary / non-confirming

Prefer Not to Answer

Race / Ethnicity*

African American / Black

Asian

White

Hispanic/Latino

American Indian/Alaskan Native

Native Hawaiian/Pacific-Islander

Other

Prefer Not to Answer

If Race is Other, What Race / Ethnicity Are You?

Year of Diagnosis*

Month of Diagnosis*

Please specify details about your breast cancer diagnosis.*

Breast Cancer Stage

Are you Still in Active Treatment?*

Yes

What was the end date of your active treatment? (mm/yy)

(Provide last date of any chemo, radiation or scheduled surgeries.)

Brief description of treatment/procedures*

Please list any medical centers where you were treated, including doctors or social workers.

Why would you like to become a Mentor?*

When are you available to make contact with mentees?*

Days

Evenings

Weekends

Weekdays

Select all that apply.

Preferred way to interact with Mentee*

Phone

In Person

Select all that apply

Please list any languages you speak other than English.

Preferred Language

Have you attend a PLP program or event? Describe the impact it had on you.

Check boxes to confirm that you:

Would like to sign up for general email blasts which include PLP’s monthly program information.

Would like to sign up for email blasts for metastatic breast cancer patients which include quarterly newsletters and information on MBC related events.

Program Expectations & Procedures*

I have read, understand and agree to the expectations & procedures.

I understand that even though I've completed the application, does not guarantee that I will be chosen. I will attend a required training to become a Mentor volunteer with the Pink Lemonade Project.

If you mentored someone or contacted a mentee, please fill out the form below.

Mentor First Name*
Mentor Last Name*
Mentor Email*
Mentee First Name*
Mentee Last Name*
Date of Contact*
MM slash DD slash YYYY
Communication Method*
What resources did you provide for support?*
Was the interaction meaningful?*
Were there any concerns brought up?*
Other notes:*

If you were contacted by a mentor and want to provide feedback, please fill out the form below.

Your First Name*
Your Last Name*
Your Email*
Mentor First Name*
Mentor Last Name*
Type of contact made*
Please describe how your connection with a Mentor went.*
What went well? How can we improve?
Would you like to be connected to another Mentor?*
If so, why?
This program is beneficial to those affected by breast cancer?*
- Strongly Agree
- Agree
- Neutral
- Disagree
- Strongly Disagree
Other Feedback

Pink Peers Mentorship

ONE-ON-ONE WITH A PEER MENTOR

More About Pink Peers Mentorship Program

Step 1: Complete the Form Below

Step 2: Complete the ROI Form

Request a Mentor Form

Nurse or Social Worker Info

Step 1: Submit the Become a Mentor Form Below

Step 2: Complete the ROI Form

Become a Mentor

ONE-ON-ONE
WITH A PEER MENTOR