Caregiver Mentee Form

To provide compassion, support and guidance to ease the brain tumor journey, the  American Brain Tumor Association’s (ABTA) Patient and Caregiver Mentor Support program pairs brain tumor patients and caregivers with “mentors” who have been through a similar experience with diagnosis, treatment and care. The Patient and Caregiver Mentor Support program is limited to those who:

Are age 18 or older

Were diagnosed with a central nervous system (brain/spine) tumor
Reside in the United States or Canada

If you experience difficulty completing this form, please call ABTA at 800-886-2282.

Contact Information

First Name

Last Name

Preferred Phone

Phone Number

Confirm Email

Does anyone other than you use this email address?

Yes No

Street Address

City

Zip/Postal Code

State/Province

Country

America Canada

Demographic Information

Birth Date

Gender Identity

Ethnicity

Marital Status

Religion

Employment Status

Primary Language

If Other, List Language Here:

Patient Information

I am/was a Caregiver for

Patient's First Name

Patient's Last Name

Patient's Gender

Patient's Birth Date

If deceased, please enter the date the patient passed away

Tumor Information

Patient’s Brain Tumor Type

If Other Tumor Type, List Here:

Tumor Location

Diagnosis Date

Patient’s Brain Tumor Treatment Status

If Other Status, List Here:

Treatment Information

Tell Us More About The Patient's Treatment

If Other, List Here:

Family & Lifestyle

Do You Have Children?

If Yes, What Are Their Ages?

What Hobbies Or Activities Do You Enjoy?

Please Tell Us A Fun Fact About Yourself.

Emotional Well-being

Have You Ever Been Diagnosed With A Mental Health Condition

Yes No

If Yes, Please Describe

Looking back on the past week, including today, I have felt sad and/or depressed

Looking back on the past week, including today, I have felt afraid and/or anxious

Looking back on the past week, including today, I have felt lonely and/or isolated

I am able to cope with difficult feelings

I feel hopeful about the future

I have someone in my life I can connect with who understands the brain tumor experience

Additional Information

How Did You Hear About ABTA’s Patient And Caregiver Mentor Support Program?

What would you like to speak with a mentor about?

Checking this box indicates that you agree to accept the terms outlined below.

The American Brain Tumor Association (ABTA) is a not-for-profit organization that provides peer support assistance through its Patient and Caregiver Mentor Support program. The Patient and Caregiver Mentor Support program matches a patient or caregiver participant (“support seeker”) with another participant who has gone through a similar brain tumor journey (“mentor”). ABTA’s Patient and Caregiver Mentor Support program provides support seekers with an opportunity to ask personal questions and express their concerns while receiving encouragement and support from a mentor, who is uniquely familiar with the challenges that brain tumor patients and/or caregivers face. Mentors serve the Patient and Caregiver Mentor Support program on a volunteer basis and donate their time and energy to the ABTA and the patient and/or caregiver support seekers with whom they are matched. Mentor / Support seeker matches are monitored by the ABTA for no longer than one year from the date of being introduced. If at any point during the program, the mentor and/or support seeker do not believe that the match is a good fit, they should notify ABTA as soon as possible to determine next steps. After one year, the support seeker is considered to have graduated from the Patient and Caregiver Mentor Support program and will no longer be part of an active match. The support seeker may opt to renew the match at that time for another year with the same mentor or with a different mentor. It is not the role of a mentor to act as a licensed medical or mental health/healthcare professional. ABTA’s policy expresses instruction to each mentor that no mentor may recommend or endorse any specific medical or non-medical tests, products, procedures, opinions, practitioners, or other information to a support seeker or otherwise give "medical" advice to another support seeker. Furthermore, no support seeker should ever construe anything communicated by any other mentor or support seeker as medical advice, recommendation, or professional opinion. The sole purpose of the relationships set up through the Patient and Caregiver Mentor Support program is social and emotional support among participants impacted by a brain tumor diagnosis. Under no circumstances should any mentor or support seeker solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another participant. Mentor / Support seeker matches are founded, and should be based, solely to provide social and emotional support and are not intended to be substituted for professional treatment, advice, or diagnosis. Mentors / Support seekers should always seek the advice of a physician or other qualified health provider with any questions regarding any medical condition experienced by self or others. Mentors / Support seekers should neither disregard professional medical advice received from doctors nor delay in seeking professional medical advice because of communication with another ABTA member (mentor, support seeker, or any ABTA employee or other volunteer) or because of information provided by the ABTA. The information which ABTA provides through its website (www.abta.org) and other educational programming is only to be read and/or used for informational purposes and is not intended to be a substitute for professional treatment, advice, or diagnosis. If at any time a Mentor/Support seeker has reason to believe that they or a loved one may have a medical emergency or needs medical attention, they should either call 911, go to the emergency room, and/or call their doctor, as appropriate, immediately. By registering for the ABTA Patient and Caregiver Mentor Support program, I understand that I will have limited access to confidential information about my mentor match through their ABTA Patient and Caregiver Mentor Support program profile. This may include diagnosis, treatment, demographic, or other information provided by mentors. I understand that I will also have access to further information as disclosed in conversations with my mentor match. I agree to regard all information encountered during an ABTA Patient and Caregiver Mentor Support program volunteer opportunity, written or spoken, as confidential. I understand that this information is not to be shared with anyone except ABTA Staff on an as-needed basis and that this information may be shared outside of the ABTA only if my or my mentor’s personal safety is at risk. I understand that the purpose of the Patient and Caregiver Mentor Support program is to receive social and emotional support related to my or my loved one’s brain tumor diagnosis, and that program participation may be terminated if it is determined by ABTA staff that my needs or challenges exceed the intent and scope of the program. Some examples of needs or challenges that exceed the intent and scope of the Patient and Caregiver Mentor Support program include, but are not limited to the following: suicidal plans, intent, or desire; mental health concerns; substance abuse; domestic abuse; serious marital/relationship issues; inconsistency with mentor’s boundaries in terms of frequency of communication, appropriate topics for discussion, etc. I understand that if my needs and challenges exceed the intent and scope of the Patient and Caregiver Mentor Support program, an ABTA staff member will suggest other services that may be more appropriate for me. For additional information about ABTA’s Privacy Policy please visit https://www.abta.org/privacy-policy/