ACF Caregiver
Request Form
You do not have to deal with your loved one's anal cancer diagnosis and treatment alone! The mission of The HPV and Anal Cancer Foundation ("ACF") Peer Support Program is to provide personal connections to support anal cancer patients (we call them "Thrivers" rather than "Patients") and their Caregivers through the treatment process and beyond.
We are a unique resource for minimizing the fear and isolation of anal cancer. We seek to empower with emotional support and hope. We who have dealt with anal cancer are now committed to helping others celebrate the joy of life despite the battle with this cancer.
ACF's Peer Support Program is dedicated to help:
- Make the lives of anal cancer patients easier and of higher quality
- Create bonds on an emotional level
- Offer hope and inspiration
- Connect cancer patients with cancer survivors
- Answer the scary questions
- Teach family and friends how to support and understand what patients are going through
- Suggest useful resources for the patient, family, and friend
Peers do not give medical advice, but guide Caregivers to good sources of information for their Thrivers to discuss with their medical team; they listen, question, and help Caregivers understand what they are facing. Once you complete and submit this ACF Peer Caregiver Request Cancer Support Form, you will then be matched with a Peer Caregiver who has supported an anal cancer patient (Thriver"). We match you based on demographic information, cancer history, treatment, and any special requests of yours. All information is confidential and is never shared outside of the ACF with anyone except a matched peer, with the consent of the Caregiver.
We look forward to supporting you on your cancer journey.
Contact Information
First Name:
Last Name:
Country:
-select option-
USA
UK
Street Address:
Apt:
City:
State:
-select option-
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip Code:
Time Zone:
GMT (0)
Atlantic (-4)
Eastern (-5)
Central (-6)
Mountain (-7)
Pacific (-8)
Alaska (-9)
Hawaii (-10)
Primary Phone:
Mobile
Home
Work
Secondary Phone:
Mobile
Home
Work
Email Address:
Alternate Email Address:
(We are committed to your privacy and your email(s) will never be shared with an outside party other than your match without your permission)
Preferred Method of Contact:
No preference
Phone
Email
Primary Language:
Other Language(s):
Weekday - preferred contact times (select all that apply):
Morning
Afternoon
Evening
Weekend - preferred contact times (select all that apply):
Morning
Afternoon
Evening
How did you hear about The HPV and Anal Cancer Foundation's Peer to Peer Program?
Family
Friend
Internet search
Healthcare professional
Nonprofit group/cancer organization
Facebook/Twitter
ACF website
Other
Demographic Information
** We ask the following information to best match you with a peer. While most demographic questions are listed as optional, the more information you give the more effective the match. **
Date of Birth:(MM/DD/YYYY)
/
/
Gender
-select option-
Female
Male
Trans
Race (optional):
Ethnicity (optional):
Marital Status (optional):
-select option-
Married
Single
Separated
Domestic Partner
Significant Other
Divorced
Widow/Widower
Sexual Orientation (optional):
-select option-
Straight
Gay/Lesbian
Bisexual
Other
Religion (optional):
-select option-
Agnostic
Atheist
Buddhist
Christian
Christian-Catholic
Hindu
Jewish
Muslim
Other
How important was religion/spirituality in your caregiving process? (optional):
-select option-
Very important
Important
Not very important
Employment Status (optional):
-select option-
Full Time
Part Time
Retired
Disability
Stay at home partner
Unemployed
Student
Other
Did you work while caregiving?
Y
N
Have you ever had cancer?
Y
N
If so, what kind?
Caregiver Information
** The questions on this page are related to your caregiving experience. The more information you give, the better the match. **
As a caregiver, I: (Please check all that apply)
Took my loved one to appointments
Provided physical support (i.e., helping with ostomy care, bathing and cleaning)
Spoke with physicians on behalf of my loved one
Helped my loved one to make medical decisions
Provided monetary support
Administered all necessary "at home" medications (i.e., pain killers)
Provided 24 hour care for my loved one
Other
Did you experience any of the following while being a caregiver: (Please check all that apply)
Caregiver Pride
Residential Move
Missed work/wages
Job loss
Depression
Isolation
Stress
Change in relationship status (i.e., divorce, marriage or new/changed partner)
Other
Was anyone else a caregiver for your loved one with anal cancer?
Y
N
If so, what is their relationship to you?
Do you have any medical conditions that impacted your ability to perform your tasks as a caregiver?
Y
N
If so, please describe:
Cancer Information - Part 1
** The following questions are related to the anal cancer thriver you cared for in order to match you with a fellow caregiver who had a similar experience. The more information you give, the better the match. **
I am/was a caregiver for:
-select option-
My spouse or partner
My parent
My child
My sibling
My grandparent
My uncle or aunt
My nephew or niece
My cousin
My friend
My fiancé/girlfriend/boyfriend
Other
Their First Name:
Their Last Name:
Their Date of Birth:(MM/DD/YYYY)
/
/
Gender
-select option-
Female
Male
Trans
Anal Cancer:
Y
N
Date Diagnosed:(MM/DD/YYYY)
/
/
Cancer Stage:
-select option-
0
1
2
3
3A
3B
4
unknown
Did their cancer metastasize?
Y
N
Not Sure
If Yes, location:
Did their cancer recur?
Y
N
Not Sure
Date of recurrance:(MM/DD/YYYY)
/
/
Cancer treatment status:
-select option-
Newly diagnosed
Still being treated
Finished treatment less than 1 year ago
Finished treatment between 1 and 5 years ago
Finished treatment more than 5 years ago
Living with cancer as a chronic illness
Receiving hospice
Deceased
Other
What treatments were given (check all that apply):
Chemotherapy
Wait and watch
Radiation
Alternative treatment
Clinical trial
Other
Surgery
Which therapies were given? (check all that apply):
5-fluorouracil (5-FU)
Mitomycin
Cisplatin
Cetuximab
Other chemotherapy drugs
Intensity modulated radiation therapy (IMRT)
Conformal radiation therapy (CRT)
Other radiation therapy
Tell us more about their treatment including therapies/drugs not listed above:
If treated more than once, what did the rounds of treatment include?
Cancer Information - Part 2
** The more information you give, the better the match. **
Please indicate which side effects they experienced:
Allergic reactions
Burns
Infection
Skin irritation
Anxiety
Depression
Lymphedema
Urinary issues
Bone pain
Fertility changes
Neuropathy
Other side effects
Bowel mgmt
Hair loss
Sexual dysfunction
Did they have an ostomy operation?
Y
N
Are they still living with an ostomy?
Y
N
Hospital/Medical Center they were treated at:
Treating doctors:
Were they ever diagnosed with AIN (Anal pre-cancer, also called anal intraepithelial neoplasia)?
Y
N
Were they ever diagnosed with any of the following?
Adenocarcinoma
Squamous Cell Carcinoma
How long were they experiencing symptoms before cancer diagnosis?
Do they have any other medical conditions, especially those that may have affected their anal cancer experience, which may be helpful for us to know for matching purposes?
Family
Caregiver Family
Some participants want to be matched with peers who also have kids. Please feel out the following if applicable.
How many children do you have?
Birth year of oldest child? (xxxx)
Birth year of youngest child? (xxxx)
Anal Cancer Thriver Family
How many children do they have?
Birth year of oldest child? (xxxx)
Birth year of youngest child? (xxxx)
Support Questions
How would you prefer to communicate with the person you're matched with? (select all that apply)
Email
Phone
Video Chat
Text Messaging
In Person
How often do you think you would like to communicate with your Peer?
-select option-
One or two conversations
Daily
Weekly
Every other week
Monthly
I'm not sure
As much as is needed
Which of the following would you like to speak with a Peer about? (check all that apply)
I just want to speak with someone who understands what I'm going through
Experience with caregiving during and post treatment
Parenting and caregiving
Communicating with family and friends
Sex/dating/relationships/intimacy
Changes to diet
Working during my loved one's treatment
Complementary/Integrative therapies for my loved one's treatment
Adjusting to life after caregiving
Hospice and end of life care
Other
Is there anything else we should know as we seek to match you with a Peer? Please list any other match criteria that is important to you:
Terms of Use
I hereby confirm that the information provided in the above application is true and complete to the best of my knowledge. I understand that false information may disqualify me from consideration as a volunteer. My act of filling out the aforementioned form gives my consent to perform a background check. I will consider all information that I gain in my volunteer position to be confidential. I understand that my volunteer service will be terminated in an event of breach of confidentiality.
Conditions of submission:
I agree to the conditions of submission:
*
Y
N
The HPV and Anal Cancer Foundation ("ACF") is a not-for-profit organization that provides peer support assistance by connecting people who are currently fighting anal cancer (each, a "Thriver") with another individual who has faced anal cancer, in his or her lifetime (each, a "Peer Mentor"). Oftentimes, a family member or friend of a Thriver will seek support from ACF (each, a "Caregiver") and ACF gladly pairs them with someone else who has supported a person with anal cancer (each, a "Peer Caregiver" and together Thrivers, Caregivers, Peer Mentors, and Peer Caregivers, "Participants"). ACF's Peer Support Program gives each Thriver and/or Caregiver a chance to ask personal questions and express his or her worries and frustrations to, while receiving encouragement and support from, someone who is uniquely familiar with the challenges that Thrivers and/or Caregivers face.
Peer Mentors and Peer Caregivers are volunteer-mentors only and donate their time and energy to ACF and to the Thrivers and Caregivers with whom they develop contacts and relationships. Participants (Peer Mentors and Peer Caregivers or otherwise) are not, and are not part of the ACF network to act as, licensed medical or mental health/healthcare professionals. ACF's policy and express instruction to each Participant is that no Participant may recommend nor endorse any specific medical or non-medical tests, physicians, products, procedures, opinions, or other information to another Participant or otherwise give 'medical' advice to another Participant. Further, no Participant should ever construe anything relayed to him or her by any other Participant as medical advice, recommendation, or opinion. The sole purpose of the relationships set up through ACF is the offering and receipt of cancer support. Under no circumstance should any Participant solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another Participant.
By answering the question below, you (a Participant) expressly indicate your understanding that the relationships established among any of the Participants are founded, and should be based solely on support (as indicated herein) and are not intended to be substitutes for professional treatment, advice, or diagnosis. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding any medical condition, whether it be yours or another person's. Please do not disregard professional medical advice you have received from your doctors or delay in seeking professional medical advice because of a communication with another ACF member (Thriver, Caregiver, Peer Mentor, Peer Caregiver, or any ACF officer, director, employee, or other volunteer) or because of something you have read on our website. The content of ACF's website (www.analcancerfoundation.org) is only to be read and/or used for informational purposes and is not intended to be a substitute for professional treatment, advice, or diagnosis. If at any time you have reason to believe you or a loved one may have a medical emergency or feel that you or a loved one need medical attention, please either call 911, go to the emergency room, and/or call your or their doctor, as appropriate, immediately.
We at the HPV and Anal Cancer Foundation are excited that you have found your way to our support network and look forward to the relationship that we will share with you.
PARENTS OR GUARDIANS OF MINORS (UNDER 18 YEARS OF AGE)
If the Participant is a minor (child under the age of 18 years) the undersigned parent and/or natural guardian or legal guardian of such Participant does hereby represent that he/she is, in fact, acting in such capacity and agrees that he/se has read these terms and conditions and understands the policies of the HPV and Anal Cancer Foundation laid out herein.
I HAVE READ AND AGREED TO THE TERMS OF USE.
*
Y
N
Please complete the application and submit online, or mail the hard copy version to:
The HPV and Anal Cancer Foundation
P.O. Box 232 · New York, NY 10272
Or
The HPV and Anal Cancer Foundation
7 Albert Mews, Albert Road · London, UK N43RD
For more information or help with the application, call us at 646-593-7739 (US)
or 0-208-133-0739(UK). You can also email us at info@analcancerfoundation.org