Apply to be a mentee and get support!

Apply to be a mentee and get support!

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Are you looking for peer support? Are you facing a challenge or want to gain knowledge from your peer? Please complete the form below. 18 years and older please. We look forward to hearing from you!

First Name

Last Name

Mobile

Email

County I live in

I prefer to be contacted by

Phone callText messageEmail

The best time to reach me is

MorningsAfternoonsEvenings

Where did you hear about this program?

Services for Independent Living - OhioAccess Center for Independent LivingLinking Employment Abilities and PotentialOther

Other

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We gather demographic information because it will help us make the best match possible.

We do not make anyone answer the questions and you can always pick "Don't want to answer". If you don't want to answer these questions you can still participate in the program.

I consider myself to be (select all that apply)

African American/BlackAmerican Indian/Alaska NativeAsianCaucasian/WhitePacific Islander/Native HawaiianBi/Multi racialDon't want to answer

Please specify

I am

HispanicNot HispanicDon't want to answer

I am

MaleFemaleTransgenderNon-binaryOtherDon't want to answer

Please specify

My birthdate is

I primarily speak

EnglishSpanishASLOther

Other language

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My disability is

Do you feel you have a general understanding of your disability?

YesNo

Why are you asking for mentor support?

Have you talked with anyone else about this issue?

What is most important for your match?

Someone with a similar disability as meSomeone who has experience with what I'm going throughSomeone who is the same gender as meSomeone who is my same race or ethnicity or cultureSomeone who is near my same ageOther

Other

Besides matching you with a mentor, is there anything else you need help with right now?

YesNo

What else do you need help with?

Someone will be in touch within 4 weekdays to talk about finding you a match.

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Contact Information