Prostate Cancer Peer Counselling Request

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Please fill out this form if you wish to be contacted by one of our volunteer prostate cancer peer counsellors for a chat.

First Name *

Last Name *

Province or territory *

City *

Email *

Best phone number to contact you *

Would you prefer to be first contacted by email or phone? *

Phone

Would you like to be matched with a peer navigator who has undergone a specific course of treatment? *

Yes

If yes, which treatment(s) are you the most interested in learning about?

If you wish to be matched with a peer counsellor who has had a similar journey to yourself, please share some details on your prostate cancer journey. Only share what you are comfortable with.

E.g. When/how you were diagnosed and at what age, your Gleason score, PSA, your treatment history thus far, or any other details you feel we should know before connecting you with a peer counsellor.

Address

Please provide us with your address if you wish to receive a free reef knot kit in the mail which includes books, pamphlets, and a wealth of information on prostate cancer to help guide you in your journey. Learn more about our reef knots kits here: www.prostatecancerbc.ca/resources/

Is there anything else you would like us to know?

Would you like to subscribe to our newsletter? *

Yes

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