Mom.ME. Mentee Application
Thank you for you interest in the Mom.ME. Peer Mentor Program.  Please complete the following application and someone from our team will be in touch with you shortly.  Sections of this application are OPTIONAL but are used to help us match our Mentors and Peers more accurately.  We are grateful you are applying and looking forward to learning more about you.
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First Name *
Last Name *
Birthdate *
MM
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DD
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YYYY
Email *
Best Contact Number *
Street Address *
City *
State *
Zip Code *
County *
Employer: (if any)
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Job Title (if applicable)
How did you learn about the Peer Mentor Program:
Demographics: (Optional)
This section is OPTIONAL, but the information will help us make the best match between Mentor and Peer.  This information will only be used by Mom.ME. and will never be shared with an outside source.
How would you describe your gender: *
Race/Ethnicity: *
Would you like to be paired with a Mentor of your same race and/or ethnicity: (we cannot guarantee this request but will do our best to accommodate)
Clear selection
Marital Status *
Are you bilingual:
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If yes, please list what language(s):
How many children do you have? *
What are their ages: (check all that apply) *
Child 1
Child 2
Child 3
Child 4
Child 5+
0-3 months
3-6 months
6-12 months
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10+ years old
Are you or your partner currently pregnant? *
If yes, what is the due date:
MM
/
DD
/
YYYY
Physician's name:
Physician's Phone:
Are you a parent of multiples:
Clear selection
Did you or your partner experience pregnancy or post birth health complications: *
If yes,  please describe:
Do you identify as a NICU parent: *
Did you or your partner go through infertility treatments:
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Have you or your partner suffered a pregnancy or infant loss:
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Have you ever served or are currently serving in the Armed Forces (U.S. Military)
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If yes, which branch:
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Perinatal Mood Disorder Information (Perinatal Mood Disorders)
This section is OPTIONAL, but the information will help us make the best match between Mentor and Peer.  This information will only be used by Mom.ME. and will never be shared with an outside source.
Even if you have not been officially diagnosed, do you believe you are suffering from a Perinatal Mood Disorder (PMD): *
If yes, which PMD(s) are you affected by: (please check all that apply)
If you selected other above, please describe:
Are you experiencing any of the following symptoms: (please check all that apply)
If you selected other above, please describe:
If you are suffering with a PMD, where are you in your recovery process:
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If you have fully recovered, how long have you been recovered:
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Did you currently use medication as a part of your recovery:
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Did you currently see a therapist/counselor as part of your recovery:
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Are you currently or have you ever participated in any of the following programs: (check all that may apply)
If you selected other above, please describe:
Did you use any of Mom.ME. resources when you were going through your PMD: (check all that apply)
If you selected other above, please describe:
Did you or your partner breastfeed, formula feed or tube feed:
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What did/do you like to do in your spare time: *
Program Specific Questions (Required)
The following answers will further assist us in making appropriate Mentor/Peer matches. This section is required.
Who's your current support system: (check all that apply) *
If you selected other above, please describe:
What do you hope to gain by having a mentor:
Is there a specific goal you would like to achieve while in the program: *
What qualities would you like to see in a Mentor: (e.g.: good listener, empathetic, strong personality, etc.) *
Are you willing to communicate via texting or phone calls with your Mentor at least ONCE per week: *
Are you currently participating in online or in-person or  support groups: *
Are you currently participating in therapy/counseling of any kind? *
Do you consider yourself to be more of and Extrovert or Introvert?
Clear selection
Emergency Contact
Your privacy is as important to us as your emotional well-being. We do require an emergency contact #, but would only use it in a real or perceived emergency.
Name of Contact: *
Phone #: *
Relationship to you: *
I give Mom.ME. permission to contact the person listed above in the event of a crisis or emergency on my behalf: (whether actual or perceived emergency) *
Application Agreement
By submitting this application, I certify that the information above is correct to the best of my knowledge.
I agree to follow the requirements and policies set forth by the Mom.ME. Peer Mentor Program: *
Required
I agree to participate in phone calls and respond to text messages from my Mentor in a timely manner: *
I understand that submitting this application does not guarantee I will be selected for the Mom.ME. Mentor Program: *
Thank You
Mom.ME.
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