Survey - Reading for Reassurance 2021 - Living Beyond Breast Cancer

Reading for Reassurance 2021

Request Your Reading for Reassurance Books

This program is intended for women who have been diagnosed within the last 6 months, and who have children between the ages of 4-17.

Parents: please complete this form to receive your free books. [If you are assisting a parent with this application, please include their contact information below and respond to the questions with their information and preferences.]

You will be mailed 1-2 books depending on your child/children’s age, at no cost, within four weeks. The books may be used at home or in school, and can help start the conversation with your children and answer many of the questions they have about breast cancer.

Note about the parent’s information: If the parent requesting books does not have an active email address, please put in a "fake" email that includes @noemail.com (example: barbara@noemail.com).

Please provide the parent's contact information below:

Field Is Required First

Middle

Field Is Required Last

Field Is Required Street 1:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Country:

Field Is Required Email:

Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from Living Beyond Breast Cancer.

Keep me logged in. What's this?

Field Is Required How did you hear about this opportunity?

If you were referred by your healthcare provider, please provide their name:

Please provide the name of the hospital or healthcare system you go to for cancer care:

These next questions are related to your breast cancer experience. We will use this information to help choose the best books for you and your family. Please answer the questions below in a way that you feel most comfortable. Exact dates are less important to us than a general timeline.

Field Is Required When were you diagnosed with breast cancer?

Field Is Required What is your date of birth?

With which racial or ethnic background do you most identify?

If other, please describe.

Field Is Required What stage of breast cancer do you / did you have?

Have you had a mastectomy or are you planning on having one? (Specialized books on this topic available.)

Field Is Required Current age(s) of child(ren):

Field Is Required I would prefer my books to be in

English
Spanish

A summary of each book available through Reading for Reassurance is available at www.lbbc.org/reading. We will do our best to send you your first choice based on available inventory. If necessary, we will make an appropriate substitution.

Field Is Required My first preferred book is:

Field Is Required My second preferred book is:

If you are a healthcare provider assisting with this form, please provide your name, hospital/health system, and email address.