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Patient Profile for Referral to Breast Friends Resources: □Female □Male Age_______ □Newly Diagnosed/In Treatment □Breast □Ovarian □Cervical □Uterine Referral Date:_______ □Completed Treatment □ Other Cancer Notes: ********************************************************************************************* Breast Friends Support Services Available: □ Phone, or in-person, one-on-one support with survivor volunteer □ Accompany patient to chemotherapy appointments (available in the greater metropolitan Portland area) □ Monthly group support meetings (multiple locations) – Some are evenings, or afternoons, one is breakfast. □ Thriving Beyond Cancer – three-day retreat or two-day workshop facilitated by Certified Life Coach Sharon Henifin. This workshop is for women who have completed formal treatment. Purpose is to help women gain clarity and create a more fulfilled life after cancer. There is a modest charge to cover food costs, lodging and materials. Scholarships are available. (Program brochure available) Additional Resources Available: □ Our ‘Signature’ Humorous baseball caps for chemo patients □ Closet with scarves, wigs, mastectomy bras, and prosthetics, provided to patients at no charge – Tigard Office. □ Matt’s Chemo Bags full of goodies to take to chemo treatment. □ Printed guides for family, friends, co-workers and spouse/partners, kids/teens, filled with ideas on how to best support the patient. Referring clinic or medical office: Referring Physician: Patient Name: Patient Phone Number: Patient email: Patient Address: Instructions: Medical doctor or P.A. – Fill out (with patient permission), and please fax to 1-866-734-3762 Breast Friends 503-598-8048; Toll Free 888-386-8048 www.breastfriends.org, [email protected] 14050 SW Pacific Hwy, Suite 201, Tigard, OR 97224