2023-2024 Disability Peer Mentor Request

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Thank you for your interest in the Disability Peer Mentor Program (DPMP)! We're glad you're here.

DPMP pairs students with similar disabilities to create a community of support and mentorship for students. We define "disability" broadly in our program, but our matching is highly individualized and identity-based. The following questions help us understand your needs so that we can find a mentor who is a good fit. You can write as much or as little as you like and/or skip questions that do not apply to you. Note: students who are on leave or withdrawal are also welcome to seek mentors.

For a program overview, see: https://yaleconnect.yale.edu/dpmp/home/

For assistive technology mentoring specifically, sign up here: https://forms.gle/ZePu2eZ2GBifUJ8Q9

For ADHD discussion groups for undergrads, sign up here: https://forms.gle/xikSoafZqo2wNbtQ7

For ADHD discussion groups for grad students, sign up here: https://forms.gle/Hpuw1pvUmyAvY3Ba6

If you have additional questions, please contact Sara Siwiecki: sara.siwiecki@yale.edu.

First name *

Last name *

Preferred first name (if different)

Email *

Phone number

How can your mentor contact you?

Please don't contact me this way

Acceptable contact method

Preferred contact method

Phone

Text

Clear selection

Gender identity & preferred pronouns

I am a(n) *

Undergrad

Grad/Professional Student

Other:

Major/Academic program & Class Year *

With which of these disabilities do you identify? Check all that apply.

DPMP keeps all mentees' identifying information private and confidential. Only the program coordinator and your assigned mentor will see the full text of this form submission.

Physical or mobility disability

Chronic illness or autoimmune condition

Mental illness or psychiatric disability

Hearing impairment

Vision impairment

Learning disability or neurodiversity (ADHD, dyslexia, processing disorders, etc.)

PTSD or complex trauma

Concussion or traumatic brain injury (TBI)

Other temporary disability

Prefer not to disclose

Other:

Are you a user of assistive technology or interested in learning about assistive technologies available to you?

What kinds of topics would you like to discuss with your mentor? Are there particular issues you've encountered that you're looking for help in resolving?

Are there other identities you hold that have had an important impact on your experience of disability at Yale and/or that would be important for you to share with your mentor?

What qualities are the most important to you in a mentor? (e.g., specific shared identities, academic interests, approaches to mentorship)

Anything else we should know about you (hobbies, personal interests, lived experiences, etc.)?

How did you learn about the Disability Peer Mentor Program?

A Disability Affinity Group on Campus (DEFY, GSDA, Think Different, survival guides)

Academic Strategies Program

College Representative (Dean or Fro Co)

Cultural House Newsletter

DPMP Poster or Social Media Post

SAS

Personal social Network

Other

Other:

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