I would like a Recovery Mentor
First name *
Your answer
Email address you would like to use with your Recovery Mentor (By providing your email, you are giving us permission to communicate confidential information with you through this email.) *
Your answer
Phone number you would like to use with your Recovery Mentor (they can call or text you) *
Your answer
If you are under the age of 18, we require a parent's email address and phone number contact to sign off on Recovery Mentorship Guidelines and Disclaimers.
Parent's name
Your answer
Parent's email address contact
Your answer
Parents telephone number contact
Your answer
If you are comfortable providing the following information, this will help your Recovery Mentor get to know you more.
Would you like a mentor that is close to your age? *
What is your age? *
Your answer
Can you please describe who you are? (we want to show that eating disorders affect EVERYONE, no matter what gender, ethnicity, age, race, etc) *
Your answer
Would you be comfortable specifying your gender? If so, please describe below.
Your answer
Do you have a preference for a specific gender, culture, ethnicity or otherwise for your mentor? If so, please let us know. *
Your answer
What challenges with your eating disorder recovery are you currently struggling with? *
Your answer
What or who is a part of your current support community (friends, family, physicians, therapists, support groups etc)? *
Your answer
What kind of support do you want and need from a Recovery Mentor? *
Your answer
Why would you like a Recovery Mentor? *
Your answer
How did you hear or find out about the ANAD Mentorship Program? (This helps us out with promoting the program!) *
Your answer
If you found out about ANAD through google search, please let us know which terms you were searching for below.
Your answer
Would you like to subscribe to ANAD's email newsletter? *
Submit
Never submit passwords through Google Forms.
This form was created inside of ANAD. Report Abuse - Terms of Service - Additional Terms