Duet Peer Mentee Application Survey

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* 1. Mentee 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 mentor.

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* 2. What year were you born?

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* 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

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* 4. What language(s) do you speak?

English

Spanish

Other (please specify)

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* 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

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* 6. What is your gender?

Female

Male

Prefer not to answer

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* 7. Do you have any children?

Yes

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

Yes

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* 9. Do you have any grandchildren?

Yes

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* 10. Would you describe yourself as spiritual or faithful?

Yes

If yes, which faith?

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* 11. Are you a veteran?

Yes

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* 12. Are you caring for a veteran?

Yes

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* 13. Do you work outside the home?

Yes

Please let us know about your background as a caregiver.

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* 14. How long have you been a caregiver?

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

Spouse

Domestic Partner

Child

Other Relative

Friend

Other (please specify)

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

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)

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* 17. Does the care recipient live with you?

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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?

Yes

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* 20. What are some issues currently concerning you?

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

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* 22. What are some of your interests?

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* 23. What is today's date?

Date / Time

Date

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