OCRA's Steps 1:1 Counseling team is here with comprehensive support to help those diagnosed with or impacted by gynecologic cancer live well emotionally, mentally, and physically.

Wherever you are in your cancer experience, we respect your unique situation and the aspects of life you care about most. Through a series of individual phone calls or videoconferences, our professional Counselors are ready to help understand who you are, how you feel, your concerns, and how OCRA's Steps program can become a trusted partner.

Your Steps Counselor can help you:

• Increase understanding of the gynecologic cancer experience
• Expand stress reduction skills
• Strengthen communication and self-advocacy skills
• Enhance coping and resilience skills
• Ease emotional burden of diagnosis

We listen to your concerns and provide a safe space for conversation and exploration.

All of OCRA's services are provided free of charge.

* denotes required fields

Getting Started

I am a:

Patient or Survivor Caregiver (active), Family member, or Friend of someone diagnosed with cancer

What is your/their cancer diagnosis?

Are you 18 or older?

YesNo

Do you live in the United States?

YesNo

Language Spoken:

Please Note: There is a Save and Resume option to leave the form and return.

Welcome to OCRA and the Steps 1:1 Counseling Program

Our team is here to provide comprehensive whole-person support so that you can live a full life while managing the impact of gynecologic cancer.

Following is your registration form which includes:

Questions about your contact and communication preferences so we can personalize how we stay in touch.
Questions and a survey of topics about your cancer diagnosis, current status and concerns. Your answers inform how your Counselor starts a conversation with you, sets priorities, tracks your progress and personalizes your Steps Counseling sessions.
A consent and confidentiality agreement to be sure you understand and approve how we handle your information.

Completing this form should take approximately 10-15 minutes.

Please Note: You can Save and Resume (upper right) during any part of this registration.

Welcome to OCRA and the Steps 1:1 Counseling Program

Our team is here to provide comprehensive whole-person support so that you, as a caregiver, can live a full life while managing the impact of gynecologic cancer.

Following is your registration form which includes:

Questions about your contact and communication preferences so we can personalize how we stay in touch.
Questions about your loved one's diagnosis and current treatment status, as well as your personal concerns. Your answers inform how your Steps Counselor starts a conversation with you, sets priorities, tracks your progress and personalizes Steps Counseling sessions.
A consent and confidentiality agreement to be sure you understand and approve how we handle your information.

Completing this form should take approximately 10-15 minutes.

Please Note: You can Save and Resume (upper right) during any part of this registration.

Thank you for your interest

Thank you for reaching out to OCRA's Steps 1:1 Counseling program.

Currently, we accept individuals into the Steps program who are:

• Diagnosed with a gynecologic cancer, or
• Active caregivers of those with a gynecologic cancer diagnosis
• 18 years or older
• Residing in the United States

One or more of these criteria has not been met on your registration form.

Please call 212-268-1002 or email support@ocrahope.org if you have questions or want to discuss options. Our team may have additional resources to share with you.

If you would like to stay in touch and receive information about Ovarian Cancer Research Alliance's programs, resources, and news, please fill out the information below.

First Name:

Last Name:

Email Address:

Address:

City:

State:

Zip Code:

Information

First Name:

M.I.

Last Name:

Date of Birth:

Email Address:

Pronouns:

Address:

City:

State:

Zip Code:

Gender:

Marital Status

Sexual Orientation

What is your relationship to the individual diagnosed?

How did you hear about Ovarian Cancer Research Alliance?

Other: How did you hear about Ovarian Cancer Research Alliance?

Emergency Contact Information

First Name:

Last Name:

Phone Number:

Relationship:

Note:

*Please note: we will only contact this number in case of emergency.

Patient Information

Survivor First Name

Survivor Last Name

Age of Survivor:

Survivor's City

Survivor's State:

The Survivor I am supporting is currently receiving or has received support through the Steps program:

YesNoI am unsure

Physician Information

The physician I rely on the most is:

Please identify the Physician relied on most during your loved one's cancer journey.

Physician First Name:

Physician Last Name:

Physician Phone and/or Email:

What is the role of this physician?

Surgical Oncologist	Medical Oncologist
Gynecologic Oncologist

Clinic Name:

City

State:

My Coordinates Survey

What are your concerns? A cancer diagnosis comes with many uncertainties. To help guide our initial conversation and address your top priorities, please complete this survey by rating your level of concern regarding the following topics.

Once your registration is completed, a Steps Counselor will reach out to schedule an initial orientation phone meeting with you. Throughout the program, your Counselor will continue to address your highest priority concerns.

Getting Started

	Not at all	Slight	Moderate	Serious	Very Serious
1. Diagnosis/Surgery: finding a gynecologic oncologist, seeking a second opinion, considering genetic risk factors, undergoing surgery, getting the confirming diagnosis.
2. Communicating with Healthcare Team: sharing concerns, requesting clarification, managing difficult conversations, and enhancing self-advocacy.
3. Deciphering Medical Jargon: understanding gynecologic oncology terms, surgical, diagnostic, pathology reports, and related written and oral information.
4. Distress of Diagnosis: managing the emotional and psychological impact of receiving an ovarian cancer diagnosis.
5. Family and Social Relationships: changing dynamics, shifting roles, and sharing responsibilities with spouse, partner, children, or other relatives, co-workers, and close friends.
6. Weighing Fertility Options: keeping reproductive organs and/or preserving eggs/ova to sustain the possibility of future pregnancy.
7. Cultural Competency: finding racially, ethnically, and culturally responsive resources and support; LGBTQIA competence resources and support or care; resources and support for people with limited to no English language skills.

Practical Matters

	Not at all	Slight	Moderate	Serious	Very Serious
8. Palliative Care/ Pain Management: addressing symptom management, comfort care, and pain control throughout cancer treatment.
9. Home-Based Support: accessing home health, homemaker or household assistance services.
10. Travel & Lodging: finding affordable transportation to medical appointments and treatments including clinical trials; finding lodging for survivors, caregivers, or family during out-of-area diagnostic, treatment, and hospital stays.
11. Financial Concerns: understanding health insurance coverage, co-pays, and statements; coordinating private and government insurance, access to financial assistance programs, and knowing the rights & responsibilities of employees with disabilities and need for extended medical leave.

In treatment

	Not at all	Slight	Moderate	Serious	Very Serious
12. Treatment Options: understanding standard of care treatments and clinical trial navigation.
13. Chemotherapy Management: learning about evidence-based and/or peer recommended methods and tips for managing chemotherapy and other treatment impacts.
14. Coping/Resilience: managing distress, anxiety, depression of the emotional aspects of illness and being able to bounce back from ongoing stressful situations.
15. Body Image: addressing the loss of female reproductive organs, surgery scars, hair loss and other physical changes.

Managing Physical & Emotional Symptoms & Side Effects

	Not at all	Slight	Moderate	Serious	Very Serious
16. Connections/ Support: finding cancer support and connections with other survivors, caregivers, and families; matching through OCRA's Woman to Woman Peer Mentor Program, learning more about advocacy, and building a support network.
17. Identity as a Patient, Survivor, Person: adjusting to self-perception and responses from friends/family during and after cancer treatment; handling well-meaning but misguided stereotypes.
18. Food/Nutrition: making healthy meal choices; consuming nutritious calories while dealing with treatment side-effects; discerning the best options among a spectrum of dietary choices.
19. Energy/Exercise: discovering ways to increase energy, to manage daily activities and maintain a desired fitness level during the cancer journey.
20. Fatigue/Sleep: addressing treatment fatigue, exhaustion, tiredness, and insomnia.
21. Complementary Therapies: finding integrative mind/body/spirit methods and approaches that may be used as supportive treatment alongside Western medicine.
22. Sexuality: expressing desires and hesitations about intimacy, sexual feelings and sexual health.

When Treatment is Completed

	Not at all	Slight	Moderate	Serious	Very Serious
23. Managing Transitions: shifting away from active treatment and moving back into the routines of daily living; adjusting to the "new normal".
24. Post Treatment Health Management: understanding survivorship care plans and issues once treatment has ended.
25. Recurrence Fear: Addressing constant worry about cancer recurrence after diagnosis, while in remission or during maintenance treatment; understanding recurrence risk.

In Case of Recurrence

	Not at all	Slight	Moderate	Serious	Very Serious
26. Detecting and Managing Recurrence: making decisions if symptoms/ markers appear again; understanding the variety of recurrent disease treatment options; managing follow-ups.
27. Emotional Impact of Recurrence: understanding emotions surrounding recurrence; maintaining hope; managing ongoing uncertainty for oneself, caregiver, and loved ones.
28. Advanced Disease Choices: understanding the pros/cons of continued treatment regimens; quantity vs quality-of-life issues; discussing options with loved ones.

Ongoing Concerns

	Not at all	Slight	Moderate	Serious	Very Serious
29. End of Life Choices / Advance Directives: making decisions and preparing documents to clarify preferences for end of life care, hospice, and life-sustaining measures.
30. Psychological Transition Toward End of Life: understanding mental and emotional shifts from fighting the disease to entering end-of-life transitions; helping family members and loved ones make the shift to acceptance and creating an environment for "dying well".
31. Spirituality: addressing big picture questions about life and death; finding support in belief structure, community or faith.
32. Long-term Survival: managing physical challenges arising from long-term effects of chemotherapy or other treatments; processing mental and emotional challenges arising from all aspects of the cancer experience.

Personal Goal

What is the main thing you hope to achieve through your participation in this program?

My Coordinates Survey

What are your concerns? A cancer diagnosis comes with many uncertainties, for survivors as well as caregivers. To help guide our initial conversation and address your top priorities, please complete this survey by rating your level of concern regarding the following topics.

Once your registration is completed, a Steps Counselor will reach out to schedule an initial orientation phone meeting with you. Throughout the program, your Counselor will continue to address your highest priority concerns.

Please rate these topics as a caregiver, while keeping your loved one in mind.

Getting Started

	Not at all	Slight	Moderate	Serious	Very Serious
1. Diagnosis/Surgery: helping your loved one by finding a gynecologic oncologist, seeking a second opinion, considering genetic risk factors, undergoing surgery, confirming the diagnosis.
2. Communicating with Healthcare Team: helping your loved one with sharing her concerns, requesting clarification, managing difficult conversations with providers and enhancing self-advocacy.
3. Deciphering Medical Jargon: understanding gynecologic oncology terms, surgical, diagnostic and pathology reports, and related written and oral information.
4. Distress of Diagnosis: managing the emotional and psychological impact of your loved one’s cancer diagnosis.
5. Family and Social Relationships: changing dynamics, shifting roles and sharing responsibilities with spouse, partner, children or other relatives, co-workers and close friends as a result of cancer diagnosis and treatment.
6. Weighing Fertility Options: supporting your loved one in keeping reproductive organ viability and/or preserving eggs/ova to sustain the possibility of future pregnancy.
7. Cultural Competency: finding racially, ethnically and culturally-responsive resources and support; LGBTQIA competent resources and support; and/or care, resources, and support for people with no or limited English language skills.

Practical Matters

	Not at all	Slight	Moderate	Serious	Very Serious
8. Palliative Care & Pain Management: addressing symptom management, comfort care, and pain control throughout cancer treatment.
9. Home-Based Support: accessing home health, homemaker, or household assistance services.
10. Travel & Lodging: finding affordable transportation to medical appointments and treatments including clinical trials; finding lodging for survivors, caregivers, or families during out-of-area diagnostic, treatment and hospital stays.
11. Financial Concerns: understanding health insurance coverage, co-pays, and statements coordinating private and government insurance, accessing public and private financial assistance programs, and knowing the rights & responsibilities of employees with disabilities and/or need for extended medical leave.

In treatment

	Not at all	Slight	Moderate	Serious	Very Serious
12. Treatment Options: understanding standard of care treatments and clinical trial navigation.
13. Chemotherapy Management: learning about evidence-based and/or peer-recommended methods and tips for managing chemotherapy and other treatment impacts.
14. Coping/Resilience: managing distress, anxiety, depression or the emotional aspects of experiencing a loved one's illness and being able to bounce back from ongoing stressful situations.
15. Body Image: supporting your loved one in addressing her loss of female reproductive organs, surgery scars, hair loss and other physical changes.

Managing Physical & Emotional Symptoms & Side Effects

	Not at all	Slight	Moderate	Serious	Very Serious
16. Connections/Support: finding cancer support and connections with other survivors, caregivers and families; matching through OCRA's Woman to Woman Peer Mentor Program, learning more about advocacy, and building a support network.
17. Identity as a Caregiver: adjusting one's self-perception. Handling well-meaning but misguided comments and stereotypes from friends/family.
18. Food/Nutrition: making healthy meal choices for yourself and your loved one; helping your loved one consume nutritious calories while dealing with treatment side-effects; discerning the best options among a spectrum of dietary choices.
19. Energy/Exercise: discovering ways to increase energy, manage daily activities and maintain a desired fitness level, for yourself or your loved one, during the cancer experience.
20. Fatigue/Sleep: addressing treatment fatigue, exhaustion, tiredness and/or insomnia as a caregiver, or to help your loved one.
21. Complementary Therapies: finding integrative mind/body/spirit methods and approaches that may be used as supportive treatment alongside Western medicine.
22. Sexuality: expressing desires and hesitations about intimacy, sexual feelings and sexual health.

When Treatment is Completed

	Not at all	Slight	Moderate	Serious	Very Serious
23. Post-Treatment Health Management: understanding survivorship care plans and issues once treatment has ended.
24. Managing Transitions: shifting away from active treatment and moving back into the routines of daily living; adjusting to the "new normal".
25. Recurrence Fear: addressing constant worry about cancer recurrence after diagnosis, while in remission or during maintenance treatment; understanding recurrence risk.

In Case of Recurrence

	Not at all	Slight	Moderate	Serious	Very Serious
26. Detecting and Managing Recurrence: making decisions if symptoms/markers appear again; understanding the variety of recurrent disease treatment options; managing follow-ups.
27. Emotional Impact of Recurrence: understanding emotions surrounding recurrence; maintaining hope; managing ongoing uncertainty for oneself, survivor and loved ones.
28. Advanced Disease Choices: understanding the pros/cons of continued treatment regimens; quantity versus quality-of-life issues; discussing options with survivor and loved ones.

Ongoing Concerns

	Not at all	Slight	Moderate	Serious	Very Serious
29. End of Life Choices/ Advance Directives: supporting your loved one in making decisions and preparing documents to clarify preferences for end-of-life care, hospice, and life-sustaining measures.
30. Psychological Transition Toward End of Life: understanding mental and emotional shifts from fighting the disease to entering end-of- life transitions; helping family members and loved ones make the shift to acceptance and creating an environment for "dying well."
31. Spirituality: addressing big picture questions about life and death; finding support in belief structure, community or faith.
32. Long-Term Survival: supporting your loved one in managing ongoing challenges arising from long-term effects of chemotherapy or other treatments; processing mental and emotional challenges, as a caregiver, arising from all aspects of the cancer experience.

Personal Goal

What is the main thing you hope to achieve through your participation in this program?

Steps Counseling ("Steps") is a virtual support program of Ovarian Cancer Research Alliance ("OCRA") for gynecologic cancer patients, survivors and caregivers. Please review the following statements about the program and confirm your acknowledgment by checking the box provided.

Steps provides emotional and psychoeducational support to help manage the uncertainties of the gynecologic cancer experience, including assistance with stress management, resource planning, and accessing social services. Steps is not intended to provide any medical advice, treatment, diagnosis, or other medical services. Steps is not intended to provide psychotherapy, crisis management or in-depth mental health services. OCRA does not endorse any particular healthcare provider, treatment, organization, or resource. Any changes you wish to make as a result of your participation in our program are subject to your own discretion. All treatment questions and decisions, physical or emotional symptoms or concerns, and related diagnosis questions, should and must be discussed with your healthcare provider.

Acknowledged

As a participant in Steps, you will be matched with an oncology social worker through Steps or Iris, with whom you will meet by phone or videoconference up to ten (10) times over the course of six (6) months. There are potential risks to videoconferencing technology, including interruptions and unauthorized access. Your assigned Counselor will communicate with you exclusively through a secure and confidential platform managed by OCRA or Iris, which may include videoconference, text message, email, or phone. You should avoid sharing any personal information with your Counselor through any other communication channel. OCRA cannot guarantee the privacy or security of personal information sent through any alternative channel.

Acknowledged

OCRA will share your application information with Iris if they are to deliver your counseling. Except as required by law, OCRA and Steps will not supply your name, contact information or personal information to any third parties without your prior written consent.

Acknowledged

You may withhold or withdraw from the Steps program at any time. Additionally, you may withhold or withdraw by providing OCRA with written notice. Otherwise, this consent will be considered renewed and ongoing upon each meeting between you and your Counselor during your participation in the Steps program.

Acknowledged

In consideration for your participation in the Steps program, you agree to indemnify, defend, release and hold harmless OCRA and Iris, their employees, officers, directors, agents, successors and assigns, against all liabilities, claims, causes of action, damages, judgments, costs or expenses, including attorney's fees, caused by, resulting from or which arise in connection with your participation in OCRA's Steps program and virtual services.

Acknowledged

Acknowledgement of My Consent

BY CHECKING THIS CONSENT, I CERTIFY THAT:

I am submitting this form on my own behalf.

I have carefully read and consent to the terms and conditions stated herein.

I understand that this document contains a release of claims, which affects my legal rights.

Full Name

Date