BIANJ Peer Mentor Program: Mentor Interest Form

Email Address *

Phone number

BIANJ is looking to re-establish a peer mentoring program to support people newly impacted by brain injury. Mentors typically have years of experience and will provide support to help others navigate the brain injury community and resources.

Full Name *

Are you a caregiver or person with brain injury? *

Caregiver

Person with brain injury

What is your age? *

Street Address *

Address Line 2

City *

State *

Zip Code *

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?

Training for New Mentors

All mentors will participate in a virtual training. Please indicate 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)

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