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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
MM
/
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/
YYYY
Are you interested in being a Parent Mentor or a New Parent Mentee?
Parent Mentor
New Parent Mentee
Clear selection
Parent/Guardian Name(s)
Your answer
What is your phone number?
Your answer
What is your email address?
Your answer
What is YOUR age?
Your answer
What is YOUR gender?
Male
Female
Non-binary
Prefer not to say
Other
Clear selection
What is the diagnosis of your CHILD? (please list diagnosis)
Your answer
Select your CHILD's stage of Chronic Kidney Disease (CKD) or End-Stage Renal Disease (ESRD):
CKD 3
CKD 4
ESRD/CKD 5
On dialysis - Peritoneal dialysis (PD)
On dialysis - Hemodialysis (HD)
Post transplant
Clear selection
What is your CHILD's gender?
Male
Female
Non-binary
Prefer not to say
Other
Clear selection
What is your CHILD's current age?
Your answer
CHILD's age when diagnosed?
Your answer
YOUR marital status
Married
Living together but not married
Seperated
Divorced
Single parent
Widow
Other:
Clear selection
What is your relationship to the child?
Mother
Father
Grandparent
Other:
Clear selection
How long ago was your CHILD diagnosed?
A few weeks ago
3 months ago
6 months ago
1 year ago
3 years ago
5 years ago
10 years ago
Other:
Clear selection
From where do YOU primarily receive support? (Select all that apply)
Family
Friends
Business
Religion
Government
Hospital/clinic
I don't receive support
I don't receive enough support
What languages are spoken at home (select all that apply)
English
Spanish
Other:
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