Imerman Angels Caregiver Support Form

Contact Information

Hidden Fields









Address








By providing us your email address, you consent to being contacted by Imerman Angels for matching purposes including scheduling assessments, introduction to your Mentee or Mentor Angel and general correspondence from our Cancer Support Specialists.


Demographic Information

It's important to us to know the community we work with, so we can best serve them. By providing this information, we can get a greater sense of who you are in order to provide the best match.

Information provided will be kept anonymous and you can decline to answer any of these questions. Please respond as best you can. 
While we are trying to be inclusive for each of the questions below, we recognize there could be errors. If you find these options to be limiting, please select "Prefer to self identify" and let us know how you identify in the open-text question.









MM/DD/YYYY format. This helps us match you with someone as close to your age as possible.


This is your preferred language for receiving/giving support to or from Imerman Angels.


This is another language you would feel comfortable using to receive/give support to or from Imerman Angels.


Please share additional languages that you would feel comfortable using to receive/give support to or from Imerman Angels.






Please only select up to 5 employment industries


Information About Your Family Member or Friend







MM/DD/YYYY format









If you selected "Other cancer treatment status" above please explain

If applicable, MM/DD/YYYY format. If you are not sure of the day/month, please enter approximate values.




MM/DD/YYYY format. If you are not certain of the day/month, please enter approximate values.





Their Treatment Information



Please tell us more about the treatment.

If they have had more than one type of treatment, please click Add another treatment.

Family and Lifestyle





If yes, how many children are living with you at each of the following ages?  Click the Add link to add another row if needed.


(Example: running, biking, swimming, rowing, team sports, climbing, etc)


Support Questions


Select All That Apply

Select All That Apply



Select All That Apply


Baseline Survey

NOTE: All questions are required.

Looking back on the past week, including today, how often have you felt each of the following? 

1 - never 2 - once in a while 3 - sometimes 4 - often 5 - always

Please rate to the extent that you agree with the following statements:

1 - strongly disagree 2 - disagree 3 - neither disagree nor agree 4 - agree 5 - strongly agree

Terms of Use

Imerman Angels (“IA”) is a nonprofit organization that provides one-on-one cancer support by connecting cancer fighters, survivors, caregivers, those who are high risk, and others seeking support (each a “Support Seeker”) with volunteer-mentors who have experienced something similar and donates their time and energy to IA and to those seeking support (each a “Mentor Angel”). IA’s one-on-one support gives each person seeking support a chance to ask personal questions and express their worries and frustrations, while receiving encouragement and support from someone who is uniquely familiar with the challenges that they may face.

By requesting support from a Mentor Angel or seeking to become a Mentor Angel (each Support Seeker and Mentor Angel referred to as a “Participant”) through IA and/or www.ImermanAngels.org (the “Website”), you expressly indicate that you understand and agree with the following:

  • The relationships established among any of the Participants are founded, and should be based, solely on psychosocial support and are not intended to be substitutes for professional treatment, advice or diagnosis. IA may refer Support Seekers to other agencies if IA personnel cannot find the appropriate match for the Support Seeker.
  • Mentors Angels do not provide support as licensed medical or mental health/healthcare professionals. No Participant may recommend or endorse any specific medical or non-medical tests, physicians, products, procedures, opinions, or other information to another Participant or otherwise give “medical’ advice to another Participant. Further, no Participant should ever construe anything relayed to them by any other Participant as medical advice, recommendation or opinion. Under no circumstance should any Participant solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another Participant.
  • You will always seek the advice of your physician or other qualified health provider with any questions you may have regarding any medical condition, whether it be yours or another person’s. You will not disregard professional medical advice you have received from your doctors or delay in seeking professional medical advice because of a communication with another Participant or any IA officer, director, employee, or volunteer or because of something you have read on the Website. 
  • The content on the Website is only to be read and or used for informational purposes and is not intended to be a substitute for professional treatment, advice, or diagnosis. If at any time you have reason to believe you or a loved one may have a medical emergency or feel that you or a loved one need medical attention, please either call 911, go to the emergency room, and/or call your or their doctor, as appropriate, immediately.
  • The information you provide to IA will only be used as described in IA’s Privacy Policy (www.ImermanAngels.org/privacy-policy) and you consent to all actions taken by IA with respect to your information in compliance with IA’s Privacy Policy.

We at Imerman Angels are excited that you have found your way to our support community and look forward to the relationship that we will share with you.

PARENTS OR GUARDIANS OF MINORS (UNDER 18 YEARS OF AGE)

If the Participant is a minor (child under the age of 18 years) the undersigned parent and/or natural guardian or legal guardian of such participant does hereby represent that they are, in fact, acting in such capacity and agrees that they have read these terms and conditions and understand the policies of Imerman Angels laid out herein.


Email Communication Preferences
In addition to being contacted by Imerman Angels for matching purposes, we also send communications regarding Imerman Angels news, events, resources, research opportunities and more! Please opt in to our mailing list if you would like to receive more from Imerman Angels. If you do not have an email address, you may skip this section.

Contact Information