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WAD Mentorship Application Form
Preliminary requirements for participation:

1. You are over the age of 14.

2. You are actively working on recovering from ED-DMT1.

3. You are seeking support and encouragement to commit to better self-care.

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Email *
Last name *
First name *
Date of Birth (MM/DD/YYYY) *
MM
/
DD
/
YYYY
Street address *
State *
City *
Zipcode *
Current age *
Cell phone number *
Emergency Contact Name: *
Relationship to Emergency Contact *
Emergency Contact cell phone AND email: *
When were you dxd with T1D? *
How long have you been struggling with an ED? *
Name of your current Diabetes Care Provider *
Diabetes Care Provider clinic name and phone number *
How long have you been working with your Diabetes Care Provider? *
Name of Mental Health Provider (Therapist and/or Psychologist) *
Mental Health Provider clinic phone number *
Amount of time you have been under their care *
How did you hear about the WAD Mentorship program? *
Participating in this program requires your willingness to have regular communication with one our WAD Mentors. Are you ready to commit to a relationship like this? *
While the communication preferences are up to you and your future Mentor to determine, we need to know that you are willing to try your hardest to maintain appropriate responsiveness and follow through when your Mentor tries to contact you, are you ready to make this commitment? *
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