Duet Peer Mentor Application Question Title * 1. Mentor Contact Information Name * Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * Please complete the background information below to best match you with a mentee. Question Title * 2. What year were you born? Question Title * 3. What is your race? White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * 4. What language(s) do you speak? English Spanish Other (please specify) Question Title * 5. Which of the following best describes your current relationship status? Married Widowed Divorced Separated In a domestic partnership or civil union Single, but cohabiting with a significant other Single, never married Question Title * 6. What is your gender? Female Male Prefer not to answer Question Title * 7. Do you have any children? Yes No Question Title * 8. If yes, do any children live at home? Yes No Question Title * 9. Do you have any grandchildren? Yes No Question Title * 10. Would you describe yourself as spiritual or faithful? Yes No If yes, which faith? Question Title * 11. Are you a veteran? Yes No Question Title * 12. Do you work outside the home? Yes No Question Title * 13. How many people are you willing to mentor at one time? 1 2 3 Please let us know about your background as a caregiver. Question Title * 14. How long were you a caregiver? Question Title * 15. What is/was your relationship to the care recipient? Spouse Domestic Partner Child Other Relative Friend Other (please specify) Question Title * 16. What is/was the diagnosis of the care recipient? Alzheimer's Disease Vascular dementia Frontotemporal dementia Lewy Body Disease Parkinson's Disease Cancer Heart Disease Anxiety / Depression Paralysis / Stroke Physical Disability / Injury Other (please specify) Question Title * 17. Did you have any unique family dynamics - whether positive or negative - while you were caregiving? Question Title * 18. Did you have a supportive family situation while caregiving? Yes No Question Title * 19. What are your preferences for matching with a Mentee? Question Title * 20. What are some of your special skills or interests? Question Title * 21. What is today's date? Date / Time Date Thank you for completing this application form! We look forward to matching you with a mentee. Done
