A partnership between Patient & Community Partnership for Education in the Office of UBC Health and the community.
Name*
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House Address: *
City: *
Province: * —Please choose an option—British ColumbiaAlbertaManitobaSaskatchewanOntarioQuebecNova ScotiaNew BrunswickNewfoundland and LabradorPrince Edward IslandNorthwest TerritoriesNunavutYukon
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Preferred Method of Contact: —Please choose an option—E-mailPostal AddressPhone
Year of Birth:
1. Please describe your relationship to the individual with a chronic condition/disability, as well as your role providing care. What are the main aspects of this role that you would like to share with students as a health mentor?
2. Please describe the individual with a chronic condition/disability whom you provide care for?
3. As a caregiver mentor, you will be sharing details with students about the individual you care for and their illness. Are you able to obtain the written agreement (assent) from this individual to be able to participate in the UBC Health Mentors Program? YesNo
If no, please explain:
4. Indicate which health professionals have had a role in the care of the individual you look after: I see/have seen...
Dentist—Please choose an option—RegularlyOccasionallyNever
Dietician—Please choose an option—RegularlyOccasionallyNever
Nurse—Please choose an option—RegularlyOccasionallyNever
Occupational Therapist—Please choose an option—RegularlyOccasionallyNever
Pharmacist—Please choose an option—RegularlyOccasionallyNever
Physical Therapist—Please choose an option—RegularlyOccasionallyNever
Physician/Doctor of Medicine—Please choose an option—RegularlyOccasionallyNever
Social Worker—Please choose an option—RegularlyOccasionallyNever
Speech-Language Pathologist—Please choose an option—RegularlyOccasionallyNever
Audiologist—Please choose an option—RegularlyOccasionallyNever
Other health professional(s)
5. How did you hear about the Health Mentors Program?
6. Why are you interested in becoming a health mentor?
7. What benefit(s) do you expect you will gain from being a health mentor?
8. Please name any relevant patient/community organizations you are a member of and your role
9. Do you have any experience leading/facilitating a group?
10. Do you have any experience working with UBC or other students?
11. Where would you prefer to meet with students? —Please choose an option—UBC campusVancouver General Hospital areacommunity centreother accessible public settingown home
12. What is your usual form of transportation? How will you get to meetings?
13. Are there any health issues or other concerns that would require special accommodation in order for you to participate in the Health Mentors Program?
14. Are you able to commit to the time requirements of this 9-month program, including the mandatory orientation expected to be on an evening in late September / early October 2024 and the symposium in early April 2025?
15. Are you / Have you been a Health Care Professional? If yes, when were you last in practice??
Reference Name 1:
E-mail:
Relationship:
Business/Organization (if applicable):
Reference Name 2:
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