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Patient Mentor and Mentee







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ABTA CommYOUnity™ Connect Patient Profile


In an effort to provide compassion, support and guidance to ease the brain tumor journey, the 

American Brain Tumor Association CommYOUnity™ Connect program pairs newly-diagnosed brain tumor patients and caregivers with “Mentors” who have been through a similar diagnosis. Often the best “medicine” is talking with someone who has walked in your shoes.

 

Once you have submitted your profile you will be redirected to a webpage to schedule a brief conversation with an ABTA Specialist. We look forward to speaking with you soon.

 

Please note: The American Brain Tumor Association is currently only matching ABTA CommYOUnity™ Connect members in the United States. Please feel free to still complete the profile and we will keep the information in our secure database for potential future endeavors.

Contact Information

Providing an email enables us to more effectively respond to your needs and support requests. We are committed to your privacy and your email will never be shared with an outside party.

Address Information

Demographic Information
These questions help us to find your ideal match.

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MM/DD/YYYY format. If you are not certain of the day or month please enter approximate values.

Treatment Information

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Family and Lifestyle

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Support Questions

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For Mentor Application Only
Note: All answers are required.

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Looking back on the past week, including today how often have you felt each of the following?

   
Please rate how strongly you agree/disagree with the following statements.

For Request Support Application Only
Note: All answers are required.

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Please rate how strongly you agree/disagree with the following statements.

Terms
and Agreement for CommYOUnity™ Connect application

The American Brain Tumor Association (ABTA) is a
not-for-profit organization that provides peer support assistance through its
peer mentoring program, CommYOUnity™
Connect Peer Support Network
. CommYOUnity™
Connect
matches a patient or caregiver participant who is currently facing
the challenges of a brain tumor diagnosis (“Mentee”) with another participant who
has gone through a similar brain tumor journey (“Mentor”). ABTA’s CommYOUnity™ Connect provides Mentees
with an opportunity to ask personal questions and express their worries and
frustrations, 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 CommYOUnity™
Connect
program on a volunteer basis and donate their time and energy to the
ABTA and to patient and/or caregiver Mentees with whom they are matched. It is
not the role of a Mentor to act as a licensed medical or mental
health/healthcare professional. ABTA’s policy and express instruction to each
Mentor is that no Mentor may recommend or endorse any specific medical or
non-medical tests, products, procedures, opinions, practitioners, or other
information to a Mentee or otherwise give “medical” advice to another
Mentee. Furthermore, no Mentee should ever construe anything communicated by
any other Mentor or Mentee as medical advice, recommendation, or professional
opinion. The sole purpose of the relationships set up through the CommYOUnity™ Connect program is social
and emotional support among participants impacted by a brain tumor diagnosis.
Under no circumstance should any Mentor or Mentee solicit or offer
professional, financial, medical, or other similar advice or assistance from or
to, respectively, another participant. 

 

Mentor/Mentee matches are founded, and should be based,
solely to provide social and emotional support and are not intended to be
substitutes for professional treatment, advice, or diagnosis. Mentors/Mentees
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/Mentees should neither disregard professional medical advice
received from doctors nor delay in seeking professional medical advice because
of a communication with another ABTA member (Mentor, Mentee, or any ABTA employee
or other volunteer) or because of something read on the ABTA website. The
content of ABTA’s website (abta.org) 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/Mentee 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 your their doctor, as appropriate,
immediately.

 

Mentor Agreement

 

By signing below, I understand that I will have limited access
to confidential information about my Mentee that is contained in their ABTA CommYOUnity™ Connect Mentee Profile.
This may include diagnosis, treatment, demographic, or other information
provided by participants. I understand that I will also have access to further
information as disclosed in conversations with my Mentee match. I agree to
regard all information encountered during an ABTA CommYOUnity™ Connect 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. I agree that by signing
above, I have received the CommYOUnity™
Connect
Peer Mentor Handbook and will read it prior to engaging with my
Mentee match.

 

Mentee Agreement

 

By signing below, I understand that I will have limited access
to confidential information about my Mentor through their ABTA CommYOUnity™ Connect Mentor Profile. This
may include diagnosis, treatment, demographic, or other information provided by
participants. 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 CommYOUnity™
Connect
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. 

 

For additional information about the Health Insurance
Portability Act please visit www.hhs.gov


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