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Mom.ME. Mentor Application
Contact Information
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Email
*
Your answer
Best Contact Number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
County
*
Your answer
Employer: (if any)
Your answer
Job Title (if applicable)
Your answer
How did you hear about the Mom.ME. Mentor Program:
Your answer
Are you willing to stay on as a Mentor after your 6-month term with your assigned Peer is completed?
Yes
No
Undecided
Clear selection
Are you interested in mentoring multiple Peers at once?
Yes
No
Undecided
Clear selection
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:
*
Female
Male
Prefer not to say
Other:
Race/Ethnicity:
*
African American
Caucasian
Asian
American Indian or Indian Native
Hispanic
From Multiple Races
Native Hawaiian or other Pacific Islander
Prefer not to answer
Marital Status
*
Married
Single
Domestic Partner
Separared
Divorced
Widow
Other
Are you bilingual:
Yes
No
Clear selection
If yes, please list what language(s):
Your answer
How many children do you have?
*
0
1
2
3
4
5+
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
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?
*
Yes
No
Maybe
Are you a parent of multiples:
NO
Yes, Twins
Yes, Triplets
Yes, 4 or more
Clear selection
Did you or your partner experience pregnancy or post birth health complications:
*
Yes
No
Rather not say
If yes, please describe:
Your answer
Do you identify as a NICU parent:
*
Yes
No
Unsure
Did you or your partner go through infertility treatments:
Yes
No
Rather not disclose
Clear selection
Have you or your partner suffered a pregnancy or infant loss:
No
Yes, pregnancy loss
Yes, loss of an infant
Yes, loss of a multiple
Yes, ectopic
Yes, stillbirth
Yes, multiple losses
Yes, Other
Clear selection
Have you ever served or are currently serving in the Armed Forces (U.S. Military)
No
Yes, I am currently serving
Yes, I have served
Clear selection
If yes, which branch:
Air Force
Army
Coast Guard
Marine Corps
Navy
Reserve
Other
Clear selection
PMD 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.
Are you a survivor of postpartum depression and/or anxiety, even if you have not been officially diagnosed:
*
Yes
No
Not sure
If yes, which PMD(s) were you affected by: (please check all that apply)
Postpartum Anxiety (PPA)
Postpartum Bipolar Disorder
Postpartum Depression (PPD)
Postpartum OCD (PPOCD)
Postpartum Post Traumatic Stress Disorder (PPPTSD)
Postpartum Psychosis (PPP)
Postpartum Rage
I am not sure
Other
If you selected other above, please describe:
Your answer
Did you experience any of the following symptoms when you had your PMD(s): (please check all that apply)
Intrusive Thoughts
Suicidal Thoughts
Insomnia
None of the Above
Other
If you selected other above, please describe:
Your answer
If you did suffer with a PMD, where are you in your recovery process:
Beginning of my recovery
Middle of my recovery
Almost fully recovered
Fully recovered
I'm not sure
I did not suffer with a PMAD
Other
Clear selection
If you have fully recovered, how long have you been recovered:
0-6 months
6-11 months
1 year
2 years
3 years+
Clear selection
Did you use medication as a part of your recovery:
Yes
No
I prefer not to answer
Clear selection
Did you see a therapist/counselor as part of your recovery:
Yes
No
I prefer not to answer
Clear selection
During your PMD treatment, did you participate in any of the following programs: (check all that may apply)
Inpatient Care
Partial Hospitalization
Intensive Outpatient (IOP)
I did not participate in a program
Other
If you selected other above, please describe:
Your answer
Did you use any of Mom.ME. resources when you were going through your PMD: (check all that apply)
I called/texted local warmline
I spoke with my local Mom.ME. Coordinator to find resources in my area
I attended Mom.ME. Support Groups
I received counseling through the pilot program
I joined the Mom.ME. private Facebook group
I've browsed the Mom.ME. website
I was not aware of Mom.ME. when I was going through my PMD
Other
If you selected other above, please describe:
Your answer
Did you or your partner breastfeed, formula feed or tube feed:
Breastfeed
Formula feed
Both
Tube feed
Other
Clear selection
Program Specific Questions (Required)
The following answers will further assist us in making appropriate Mentor/Peer matches. This section is required.
Have you ever been a Mentor before:
*
Yes
No
If yes, with what organization and what year(s):
Your answer
Why do you want to become a Mentor with Mom.ME.:
Your answer
What do you hope to gain personally from becoming a Mentor:
Your answer
What do you hope your Peer will gain through this process:
Your answer
With your current time commitments, are you able to dedicate at least 30 minutes a week to your Peer? This time will be spread between phone calls, text messaging and possible online meetings:
Yes
No
I need more information
Clear selection
Are you willing to communicate via texting or phone calls with your Peer at least ONCE per week:
*
Yes
No
I need more information
Do you currently lead or facilitate an in-person or online support group:
*
Yes
No
Please list any other volunteer work you are currently involved with: (ex. PTA, church, little league coach, etc.)
Your answer
What do you like to do in your spare time:
Your answer
Do you consider yourself to be more of and Extrovert or Introvert?
Introvert
Extrovert
Not Sure
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:
*
Your answer
Phone #:
*
Your answer
Relationship to you:
*
Your answer
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)
*
Yes
No
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 Mom.ME.'s Peer Mentor Program:
*
Yes
No
Required
I agree to participate in phone calls and respond to text messages from my Peer in a timely manner:
*
Yes
No
If selected as a Mentor, I agree to provide a two-week notice if I must step away from the program: (this does not include emergencies)
*
Yes
No
I understand that submitting this application does not guarantee I will be selected for the Mom.ME. Mentor Program:
*
Yes
No
Thank You
Mom.ME.
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