BIASC Peer Mentor Program Interest Form

A peer mentorship program is a program that includes one or more people of similar experience working together to help each other grow through support.
A peer is someone that has a shared experience. A mentor is someone that shares a similar experience and helps another person through support and by working together.
Please complete this form if you would like to attend our next BIASC Peer Mentor Training to become a Peer Mentor.

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* 1. Do you have a brain injury?

(This is a requirement for the peer mentor program)

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* 2. How old were you when your brain injury happened?

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* 3. What is your first and last name?

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* 4. What is your phone number and/or email address?

(Note: you will be contacted after submission of this Interest Form.

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* 5. What county do you live in?

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* 6. How old are you?

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* 7. What is the best time to contact you? (Ex: morning, afternoon, evening)

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* 8. Are you available to meet January 5-9th week for one 2 hour virtual training?

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* 9. If yes, what day and time works best for you?

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* 10. List 2 contacts and their phone numbers and/or emails who would recommend you as a peer mentor

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* 11. Questions/ Comments/Additional Information

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