BIANJ Peer Mentor Program: Mentor Interest 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 enroll in the program as either a Peer Mentor or Peer Partner, or would like to refer someone to the program, please share the following information:

Full Name *

Email Address *

Phone number

Street Address *

Address Line 2

City *

State *

Zip Code *

I would like to: *

Apply to become a Peer Mentor (guide others)

Apply to be matched with a Peer Mentor (receive guidance)

Are you a caregiver or person with brain injury? *

Caregiver

Person with brain injury

What your date of birth * +

What typeof 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? *

What is your highest level of education?

Are you currently working? *

YES

NO

What is/was your occupation?

Next Steps
All Peer Mentors must complete a virtual training, and peer partners will complete a screening call. Please indicate your general availability:

What days work best for you? Choose all that apply. *

What times of day work best for you? Check all that apply. *

Early morning (8:00am - 10:00am)

Late morning (10:00am-12:00pm)

Early Afternoon (12:00pm-3:00pm)

Late Afternoon (3:00pm-6:00pm)

Evenings (6:00pm-9:00pm)

What is the best way to contact you? *

Phone call

Text

Email

Fall	Motor Vehicle Crash	Assault	Stroke
AVM	Aneurysm	Brain Tumor	Anoxia
Sports Injury	Pedestrian Struck by Car	Cyclist STruck by Car	Other Other