Health Coaching Program for Patients with Cancer - Participation Interest

We’re honored to support patients with cancer, like you, in achieving your health and well-being goals and being your healthiest, happiest self. Please complete the form below to confirm your interest in participation, as well as help us match you with the best fit coach for your goals if you are chosen to participate in the program.

If chosen to participate, you’ll receive - at no cost to you - regular 30-minute live coaching sessions (via video, audio, or live chat) that you can schedule at your convenience, along with unlimited, asynchronous chat messaging with your dedicated health coach. Please complete the form below and you will receive an email in the next few days on the status of your participation and with further instructions.

First Name:

Last Name:

Email:

Are you currently taking a medication to treat cancer?

Yes

What kind of cancer are you undergoing treatment for?

If other, please specify:

What cancer medication are you currently taking?

If other, please specify:

How long have you been taking this medication?

What are your main goals for your health and wellbeing that you’d like support with?

Have you ever worked with a health coach before?

Yes

What concerns, if any, do you have about participating in the health coaching program?

By typing my name below, I acknowledge my interest in participating in the health coaching program for patients with cancer. I understand that participation includes attending coaching sessions, engaging in small steps between sessions as co-created with my coach according to my needs and preferences, and staying in touch with my coach. I understand this program is here to support me - at my pace and according to my capacity throughout my health journey. I understand that submitting this form and expressing interest does not guarantee my participation in the program.