Staff Intake

Internal Match Questionnaire

Hey there! Thank you for caring for the clients we work so hard to bring to CHN. Your care for our volunteers and the comfort and guidance you provide clients facing dark days is greatly appreciated. Your incredible team makes our job easier and we’re so proud to work with you! ~ XA

CHN Staff Name

CHN Staff Email

Client First Name

Client Last Name

Client Email

Client Phone

Client Address

Client City

Client State

Client Zip

Relation to the person diagnosed (self, spouse, daughter, etc.)

Client's Gender Identity

Client's Age

Best time to be reached by the Support Volunteer

How did you hear about Cancer Hope Network?

Diagnosis

Date of Diagnosis

Stage

Has there been metastasis (has the cancer spread?)? If yes, where?

Are you currently in the care of an oncologist/medical professional?

Briefly describe the treatments/procedures being administered.

Are any of these treatments especially important that the volunteer have also had?

If you have already had/are currently on treatment, are there side effects that have been especially difficult to manage?

We work to match you with the best Support Volunteer based on a wide variety of factors, including: cancer type, stage, treatment, side effects, age, location, language, and anything else that makes your experience unique. Please use the space below to indicate the factors most important to you.

Please use this drop down to select the number (0–10) that best describes how much distress you have been experiencing in the past week including today.

Is this your first time dealing with cancer? If not, please describe.

What type of emotional support do you currently have (i.e: spouse/family, friends, groups, counselor, etc.)?

Is there anything else that would help us understand your concerns and who may be the best match for you?