Parent Questionnaire for Mentors/Mentees
Please fill out to the best of your ability. We will put you in a Mentor/Mentee group based on how long your child has been diagnosed and then match you based on answers to other questions.
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Todays date
Are you interested in being a Parent Mentor or a New Parent Mentee?
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Parent/Guardian Name(s)
What is your phone number?
What is your email address?
What is YOUR age?
What is YOUR gender?
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What is the diagnosis of your CHILD? (please list diagnosis)
Select your CHILD's stage of Chronic Kidney Disease (CKD) or End-Stage Renal Disease (ESRD):
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What is your CHILD's gender?
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What is your CHILD's current age?
CHILD's age when diagnosed?
YOUR marital status
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What is your relationship to the child?
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How long ago was your CHILD diagnosed?
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From where do YOU primarily receive support? (Select all that apply)
What languages are spoken at home (select all that apply)
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