mentor Request FORM

Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please select how you identify your ethnicity (select all that apply) *

Asian

Black or African American

Hispanic or Latino

White

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Middle Eastern or North African

Prefer not to say

Other

Preferred way to be contacted by Mentor *

Text

Phone Call

Email

*

I acknowledge that Project NICU parent mentors maintain a strong commitment to the health and safety of those they serve. All communication shared between parent mentors and NICU parents is considered confidential. Exceptions to confidentiality include suicidal ideation, homicidal ideation, or notification of child abuse/neglect, or elder abuse/neglect. In the event that this information is disclosed, it is required that mentors notify the program director as well as the appropriate officials.

*

I acknowledge that Project NICU Parent Mentors provide support by sharing their own experiences during their journey. Parent mentors are not providing professional mental health services or medical advice.