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

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

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* 2. What year were you born?

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* 3. What is your race?

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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. Do you work outside the home?

Please let us know about your background as a caregiver.

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* 13. How long have you been a caregiver?

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* 14. What is your relationship to the care recipient?

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* 15. What is the diagnosis of the care recipient?

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* 16. Does the care recipient live with you?

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

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* 18. Do you have a supportive family situation while caregiving?

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* 19. What are some issues currently concerning you?

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* 20. What are your preferences for matching with a Mentor?

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* 21. What are some of your interests?

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* 22. What is today's date?

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Thank you for completing this application form! We look forward to matching you with a Mentor.

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