2021-2022 Disability Peer Mentor Request

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Thank you for your interest in the Disability Peer Mentor Program (DPMP)! We're so glad you're here. Your answers to the following questions help us ensure that your mentor is a good fit. Feel free to write as much or as little as you'd like in your responses, or to skip certain questions if they don't apply to you. If you would like more information about the program, check out the following page from its founders, the student advocacy & affinity organization Disability Empowerment for Yale (DEFY), here: https://defy.sites.yale.edu/disability-peer-mentor-program. If you know you are interested primarily in assistive technology (rather than as an addition to a general mentoring relationship), fill out this form instead or in addition: https://forms.gle/N1uprXG1DxASNxfZA. If you have any further questions, please email josephine.steueringall@yale.edu.

First name *

Last name *

Preferred first name (if different)

Email *

Phone number

How can your mentor contact you?

Please don't contact me this way

Acceptable contact method

Preferred contact method

Phone

Text

Clear selection

Gender identity & preferred pronouns

Academic program & class year *

With which of these disabilities do you identify? Check all that apply.

DPMP keeps all mentees' identifying information private and confidential. Only the program coordinator and your assigned mentor will see the full text of this form submission.

Physical or mobility disability

Chronic illness or autoimmune condition

Mental illness or psychiatric disability

Hearing impairment

Vision impairment

Learning disability or neurodiversity (ADHD, dyslexia, processing disorders, etc.)

PTSD or complex trauma

Concussion or traumatic brain injury (TBI)

Other temporary disability

Prefer not to disclose

Other:

Are you a user of assistive technology or interested in learning about assistive technologies available to you?

What kinds of topics would you like to discuss with your mentor? Are there particular issues you've encountered that you're looking for help in resolving?

Are there other identities you hold that have had an important impact on your experience of disability at Yale and/or that would be important for you to share with your mentor?

What qualities are the most important to you in a mentor? (e.g., specific shared identities, academic interests, approaches to mentorship)

Anything else we should know about you (hobbies, personal interests, lived experiences, etc.)?

How did you learn about the Disability Peer Mentor Program?

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