Are you a patient or a caregiver?
Select One Patient Caregiver
Relationship to patient
None Spouse (married) / partner Parent Child Sibling (sister or brother) Friend Other
If other relationship, please describe.
Gender Identity
None Male Female Non-Binary I prefer to self-describe
Race
Select One American Indian or Alaska Native Asian Black or African American Native Hawaiian Other Pacific Islander White Not Listed Prefer not to Answer Don't Know
Ethnicity
Select One Hispanic or Latino Not Hispanic or Latino Prefer not to answer
Would you like your volunteer to have a similar experience as you? If so, which area(s)?
What topics would you like to discuss? Select all that apply.
Please specify other language.
Communication preference
Select One Email Phone Text Any
Your time zone
Select One Pacific Standard Time (PST) Central Standard Time (CST) Eastern Standard Time (EST) Mountain Standard Time (MST)
State
Select One AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Patient diagnosis
Select One Acute lymphoblastic leukemia Acute myelogenous leukemia Adrenoleukodystrophy Chronic lymphocytic leukemia Chronic myelogenous leukemia Chronic myelomonocytic leukemia Fanconi anemia Hodgkin lympohma Hurler's syndrome (MPS-IH) Juvenile myelomonocytic leukemia Metachromatic leukodystrophy Multiple Myeloma Myelodysplastic syndromes (MDS) Myelofibrosis Non-Hodgkin lymphoma Severe aplastic anemia Severe combined immunodeficiency (SCID, all sub-types) Sickle cell disease Wiskott-Aldrich syndrome Other/Unknown
Patient is
Select One Considering transplant Preparing for transplant Post-transplant
Transplant Center (if known)
None AdventHealth for Children AdventHealth Stem Cell Transplant and Cellular Therapy Program Advocate Bone Marrow Transplant and Cellular Akron Children's Hospital Allegheny Health Network Cancer Institute Ann & Robert H. Lurie Children's Hospital Arkansas Children's Hospital Atrium Health Wake Forest Baptist Augusta University Medical Center Aurora St. Luke's Avera McKennan Hospital & University Health Center Banner MD Anderson Cancer Center Banner University Medical Center - Tucson Baptist Cancer Center Barnes-Jewish Hospital Baylor University Medical Center Be The Match BioBank Beth Israel Deaconess Medical Center BIO Ranier BIO Rushmore BIO StateStreet Brooke Army Medical Center Brown Cancer Center (BCC) C.W. Bill Young Marrow Donor Program Cardinal Glennon Children's Hospital Cedars-Sinai Medical Center Children's Hospital Colorado Children's Hospital of Los Angeles Children's Hospital of Michigan Children's Hospital of Philadelphia Children's Medical Center Dallas Children's Mercy Hospital Children's National Hospital Children's Wisconsin Childrenâs Healthcare of Atlanta â Arthur M. Blank Hospital CHOC Children's Christiana Care Health Services Christus Children's Cincinnati Cancer and Cellular Therapy Center Cincinnati Children's Hospital Medical Center City of Hope Cancer Center Phoenix City of Hope Chicago City of Hope National Medical Center Cleveland Clinic Foundation Cohen Children's Medical Center of NY Cohen Children's Medical Center of NY Colorado Blood Cancer Institute at HealthOnes Sarah Cannon Cancer Institute at Presbyterian/St. Luke's Medical Center Community Health Network MD Anderson Cook Children's Medical Center Corewell Health Dana-Farber Cancer Institute Dartmouth-Hitchcock Medical Center Duke University Health Systems, Inc. Ellis Fischel Cancer Center, University of Missouri Hospital Emory University Hospital Fox Chase-Temple University Hospital Franciscan Health, Indianapolis Fred Hutchinson Cancer Center Froedtert & the Medical College of Wisconsin Geisinger Medical Center H. Lee Moffitt Cancer Center Hackensack University Medical Center Helen DeVos Children's Hospital Henry Ford Stem Cell Transplant HonorHealth Cancer Transplant Institute Hospital Español Auxilio Mutuo Houston Methodist Hospital Inova Fairfax Hospital IU Health Blood and Bone Marrow Stem Cell Jersey Shore University Medical Center Johns Hopkins All Childrenâs Hospital Johns Hopkins University Kapi'olani Medical Center for Women & Children Karmanos Cancer Center LDS Hospital Levine Cancer Levine Children's Hospital Loma Linda University Medical Center Loyola University Medical Center Lucile Packard Children's Hospital Stanford Manning Family Childrenâs Mass General Brigham Cancer Institute Mayo Clinic AZ & Phoenix Children's Hospital Mayo Clinic Florida/Mayo Hospital Mayo Clinic Hospital, Saint Marys Campus Mayo Clinic Jacksonville (Pediatrics) Mayo Clinic Rochester MD Anderson Cancer Center MDA at Cooper University Hospital Medical City Dallas Hospital Medical University of South Carolina Medstar Georgetown University Hospital Memorial Sloan Kettering Cancer Center-Adult Memorial Sloan Kettering Cancer Center-Peds Methodist Hospital MetroHealth Medical Center Miami Cancer Institute Moffitt Malignant Hematology and Cellular Montefiore Medical Center Mount Sinai Hospital MountainView Hospital National Institutes of Health Nationwide Children's Hospital Nebraska Medicine Nemours Children's Hospital, Delaware New York Presbyterian / Columbia New York Presbyterian Hospital/Columbia University Medical Center - NewYork Presbyterian / Weill Cornell Nicklaus Children's Hospital NMDP Alternate Phenotype NMDP Non-Network Centers NMDP Painless Bone Marrow North Florida Hospital North Shore University Hospital Northside Hospital Northwestern Medicine Novant Health Forsyth Medical Center Novant Health Presbyterian Medical Center NYU Langone Health Ochsner LSU Health Shreveport Ochsner MD Anderson Cancer Center BMT and Cellular Therapy Program OhioHealth Riverside Methodist Hospital Oregon Health & Science University Orlando Health Arnold Palmer Hospital for Children Orlando Health Cancer Institute OSUWMC--James Cancer Hospital Our Lady of the Lake Hospital Penn State Health Prisma Health-Upstate Cancer Institute Rady Children's Hospital San Diego Robert Wood Johnson University Hospital Roger Williams Medical Center Roswell Park Comprehensive Cancer Center Rush University Medical Center Sanford Health Roger Maris Cancer Center Blood and Bone Marrow Transplant Program Sarah Cannon at Research Medical Center Sarah Cannon Transplant & Cellular Therapy Program at St. Davidâs South Austin Medical Center Sarah Cannon Transplant and Cellular Therapy Program at TriStar Centennial Medical Center Network Scripps Green Hospital SSM Health Saint Louis University Hospital St. Francis Cancer Center St. Jude Children's Research Hospital St. Louis Children's Hospital St. Luke's Cancer Institute Stanford Health Care Stony Brook University Hospital Strong Memorial Hospital Sutter Medical Center, Sacramento Texas Children's Hospital The Children's Hospital of Alabama The University of Kansas Cancer Center The University of Texas Southwestern Medical Center Thomas Jefferson University Hospital, Inc. Tufts Medical Center U of MD Marlene and Stewart Greenebaum UC Davis Medical Center UC San Diego Health UCI Hematopoietic Stem Cell Transplant and Cellular Therapy Program UCSF Benioff Children's Hospital - Oakland UCSF Medical Center UF Health Shands Hospital UK HealthCare UMass Memorial Medical Center UNC Hospitals University Hospitals Seidman Cancer Center University of Alabama at Birmingham University of Arkansas for Medical Sciences University of California (UCLA) University of Chicago University of Cincinnati Transplant and Cellular Therapy University of Colorado Hospital University of Illinois Hospital & Health University of Iowa Hosp & Clinics (Peds Prog) Stead Family Children's Hospital University of Iowa Hospitals and Clinics University of Miami/Jackson Memorial Hospital University of Miami/Sylvester Comprehensive Cancer Center University of Michigan Medical Center University of Minnesota University of Minnesota Medical Center and University of Mississippi Medical Center University of Oklahoma Medical Center University of Pennsylvania Medical Center University of Tennessee Medical Center University of Utah Transplant and Cellular Therapy Program at Huntsman Cancer Institute University of Utah Transplant and Cellular Therapy Program at Huntsman Cancer Institute University of Wisconsin Hospital & Clinic UPMC Children's Hospital of Pittsburgh UPMC HSCT Program USC Blood and Marrow Transplant and Cell Therapy Program UVA Health VA Commonwealth University Massey Comprehensive Cancer Ctr. VA Puget Sound Health Care System VA Tennessee Valley Healthcare System Vanderbilt University Medical Center West Virginia University Hospitals, Inc. Westchester Medical Center Yale University/Yale New Haven Hospital
Type of transplant
Select One Unrelated Allogeneic (donor was not related to you) Unrelated Allogeneic Haplo (unrelated donor who was a half match) Related Allogeneic (donor was related to you) Related Allogeneic Haplo (related donor who was a half match) Autologous (cells from self) Umbilical cord blood Haven't decided yet Don't know / remember
If other type of transplant/treatment, please describe:
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