Thank you for your interest in Duet's Peer Support Program. This application is intended to help us match you with an appropriate mentor. Please call (602) 274-5022 with any questions.

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1. Mentee Contact Information (Required.)

Please complete the background information below to best match you with a mentor.

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2. What is your date of birth?

Date

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3. What is your race? (Required.)

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4. What language(s) do you speak?

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5. Which of the following best describes your current relationship status?

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6. What is your gender?

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7. Do you have any children?

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8. If yes, do any children live at home?

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9. Do you have any grandchildren?

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10. Would you describe yourself as spiritual or faithful?

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11. Are you a veteran?

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12. Are you caring for a veteran?

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13. Do you work outside the home?

Please let us know about your background as a caregiver.

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14. How long have you been a caregiver? (Required.)

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15. What is your relationship to the care recipient?

I am the care recipient's... (Required.)

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16. What is the diagnosis of the care recipient? (Required.)

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17. Does the care recipient live with you? (Required.)

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18. Do you have any unique family dynamics - whether positive or negative - with your caregiving situation?

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19. Do you have a supportive family situation while caregiving?

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20. What are some issues currently concerning you? (Required.)

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21. What are your preferences for matching with a mentor? Please note we may only be able to accommodate preferences for mentor gender and availability.

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22. What are some of your interests?

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23. What is today's date?

Date
Thank you for completing this application form! We look forward to speaking with you.

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