Skip to content
Duet Peer Mentee Application
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.
*
1.
Mentee Contact Information
(Required.)
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 mentor.
2.
What is your date of birth?
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
3.
What is your race?
(Required.)
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
4.
What language(s) do you speak?
English
Spanish
Other (please specify)
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
6.
What is your gender?
Woman
Man
Other or prefer not to answer
7.
Do you have any children?
Yes
No
8.
If yes, do any children live at home?
Yes
No
9.
Do you have any grandchildren?
Yes
No
10.
Would you describe yourself as spiritual or faithful?
Yes
No
If yes, which faith?
11.
Are you a veteran?
Yes
No
12.
Are you caring for a veteran?
Yes
No
13.
Do you work outside the home?
Yes
No
Please let us know about your background as a caregiver.
*
14.
How long have you been a caregiver?
(Required.)
*
15.
What is your relationship to the care recipient?
I am the care recipient's...
(Required.)
Spouse
Domestic Partner
Child
Other Relative
Friend
Other (please specify)
*
16.
What is the diagnosis of the care recipient?
(Required.)
Alzheimer's Disease
Frontotemporal dementia
Vascular dementia
Lewy Body Disease
Parkinson's Disease
Cancer
Heart Disease
Anxiety / Depression
Paralysis / Stroke
Physical Disability / Injury
Other (please specify)
*
17.
Does the care recipient live with you?
(Required.)
18.
Do you have any unique family dynamics - whether positive or negative - with your caregiving situation?
19.
Do you have a supportive family situation while caregiving?
Yes
No
*
20.
What are some issues currently concerning you?
(Required.)
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.
22.
What are some of your interests?
23.
What is today's date?
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Thank you for completing this application form! We look forward to speaking with you.
