Lung Cancer Canada - Lung Cancer Canada

First Name:

Last Name:

Email Address:

Telephone number:

Province:

Are you completing this form :

For yourself
For someone else

If you are completing this form for someone else, please provide your name and contact information

Date of Diagnosis:

Type and stage of lung cancer:

Current treatment:

Previous treatment:

What are your goals for joining a support group?:

Feeling less lonely or isolated
Learning from other patient experiences
Reducing distress, depression, or anxiety
Increased sense of support
Improved skills and strategies to cope with impacts of lung cancer
Gaining a sense of empowerment, control, or hope
Increased understanding of lung cancer and my own experience with it
Receiving practical feedback and navigation support related to treatment options
Learning about health, practical, and social support resources
Feeling understood by other people with similar experiences
I am unsure at this time

(check all that apply)

Please add any other goals not mentioned above

Do you currently participate in a support group?:

Yes
No

If yes, what organization is hosting the group?:

Consent:

By submitting this form, I confirm that I have read, and agree to the group guidelines and terms laid out by Lung Cancer Canada and linked above.

Group Support