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:

Are you a caregiver or a person with brain injury? *
What type of brain injury was sustained? *
How did the brain injury occur? *
Are you currently working? *
When is the best time of day to contact you? *
What is the best way to contact you? *