Prostate Cancer Peer Counselling Request
Please fill out this form if you wish to be contacted by one of our volunteer prostate cancer peer counsellors for a chat.
Province or territory
Prince Edward Island
Best phone number to contact you
Would you prefer to be first contacted by email or phone?
Would you like to be matched with a peer navigator who has undergone a specific course of treatment?
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 describe your prostate cancer journey.
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.
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:
Is there anything else you would like us to know?
Would you like to subscribe to our newsletter?
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service