MatesCONNECT Referral
First Name
Last Name
Email
Phone
Age
Postcode
City/ Suburb
Stage of Cancer
Please select...
Localised Prostate Cancer
Locally Advanced Prostate Cancer
Metastatic Prostate Cancer
Gleason Grade / ISUP Grade:
Just diagnosed? What treatment are you deciding on?
Active Surveillance
Surgery (Open)
Surgery (Robotic)
Brachytherapy (Seed Implantation/Low Dose)
Brachytherapy (HighDose)
Radiotherapy (Primary Treatment)
Radiotherapy (Salvage Treatment)
Radiotherapy (Palliative Treatment)
Hormone Therapy (Combined with other treatment)
Hormone Therapy (Long Term)
Orchidectomy
Chemotherapy
Other (Please specify)
Please specify
If you have had treatment, what have you had?
Nothing yet. Just diagnosed.
Active Surveillance
Surgery (Open)
Surgery (Robotic)
Brachytherapy (Seed Implantation/Low Dose)
Brachytherapy (HighDose)
Radiotherapy (Primary Treatment)
Radiotherapy (Salvage Treatment)
Radiotherapy (Palliative Treatment)
Hormone Therapy (Combined with other treatment)
Hormone Therapy (Long Term)
Orchidectomy
Chemotherapy
Other (Please specify)
Please specify
What side effects / impacts do you want to know more about?
Urinary Incontinence
Urinary Incontinence (Long term following surgery)
Bowel problems
Side effects of hormone therapy
Erectile Dysfunction
Artificial Urinary Sphincter
Penile Prosthesis
Loss of libido
Relationships (Impact on relationships / Impact on sex life)
Impact on employability and ability to work
Other (Please specify)
Please specify
What would you like to discuss with a MatesCONNECT Volunteer?
What is your availability? (Days of the week, times of the day)
Can a MatesCONNECT volunteer identify that they are calling from PCFA?
Yes
No
Can a MatesCONNECT volunteer leave a voice message?
Yes
No
Would you like to be sent an evaluation survey after your call?
Yes
No
I agree that I have read and understood the
MatesCONNECT Information and Consent Form
provided to me.
I understand the type of service provided by PCFA’s MatesCONNECT program and I provide my informed consent for PCFA to confidentially collect my personal information. I confirm that I agree to receive this phone-based peer support provided by a PCFA volunteer.
I agree
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