Mentee Matching Form

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

*Please note that there is currently a waitlist for peer support.

Your responses will be kept confidential and used solely to help match you with the best mentor. Please keep in mind that peer support is intended to complement, not replace, treatment. To be paired with a mentor, you must currently be receiving some form of consistent specialized eating disorder therapeutic or medical support if you are actively in eating disorder recovery.

*A minimum age of 14 is required

Before submitting your form, we kindly ask that you take a moment to review our application page to ensure everything is in order.

Thank you!

The Silver Linings Team

Email *

Full Name: *

Phone Number *

Age: *

What province/territory do you live in? *

What city do you live in? *

Ethnicity (select all that apply):

Indigenous/Aboriginal (including First Nations, Métis, Inuit)

European (Western, Eastern, or Northern; e.g., Caucasian, White)

African (including African American, African Canadian, Black)

East Asian (e.g., China, Taiwan, Japan, Korea)

Southeast Asian (e.g., Vietnam, Philippines, Burma, Cambodia)

South Asian (e.g., India, Pakistan, Sri Lanka, Bangladesh)

Middle Eastern

West Indian/Caribbean

Mexican, South American, and Central American

Jewish

Unsure/Prefer Not to Answer

Other:

Gender:

Pronouns:

I am experiencing/have experienced the following ED related diagnoses/circumstances (select all that apply):

Binge Eating Disorder

Anorexia

Bulimia

ARFID

Atypical Anorexia/Bulimia

Over-exercising

Being hospitalized

Completing a day treatment program

Body image concerns

Having an eating disorder under the age of 16

Having an eating disorder as an older adult

Starting with anorexia, which then developed into bulimia

I would like to work with a mentor between the ages of (select all that apply):

30-34

35-40

41-45

46-50

50 plus

What eating disorder services are you currently accessing (therapist, dietician, treatment program)? Please indicate if you are currently on the waitlist for an eating disorder service. *

Briefly describe how a mentor might best support you:

Current Therapist: Name, email, and phone number (required in order to be considered for the program):

*Please reach out to jessica.sauerwein@silverliningsfoundation.ca for a list of resources if needed

Emergency Contact: Name, email, and phone number *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Silver Linings Foundation.

Does this form look suspicious? Report

Forms