BIANJ Peer Mentor Program Referral/Self-Referral Form

The BIANJ Peer Mentors connect with others who find themselves in a similar situation. Peer Mentors provide an alternative, and much needed, form of support to new caregivers or survivors during the recovery process and transition back to the community.

If you would like to be matched with a Peer Mentor, or if you would like to refer someone to be matched with a mentor, please share the following information:

Full Name *

Phone Number *

Email Address *

Street Address *

Address Line 2

City *

State *

Zip Code *

Are you a caregiver or a person with brain injury? *

Caregiver

Person with Brain Injury

What is your date of birth? * +

What type of brain injury was sustained? *

Acquired brain injury (ABI)

Traumatic brain injury (TBI)

When did the brain injury occur? * +

How did the brain injury occur? *

What are some of your hobbies/interests? *

Are you currently working? *

Yes

No

What is/was your occupation?

What are you hoping to gain from connecting with a peer mentor? *

When is the best time of day to contact you? *

Morning

Afternoon

Evening

What is the best way to contact you? *

Phone

Email

Text

Fall	Motor vehicle crash	Assault	Stroke
AVM	Aneurysm	Brain Tumor	Anoxic/hypoxic injury
Sports related	Pedestrian struck by car	Cyclist struck by car	Other Other