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CONNECT TO A PATIENT AMBASSADOR

Mentees Information Form:

Information about person with Alport Syndrome:


Needs of Mentee:


Please check all categories of mentors with whom you would be willing to be partnered.

1. Would you like to be matched with a person who has a Alport Syndrome?
No Yes

Male Female

a teenager (ages 13 – 19)
a young adult (ages 20 – 30)
an adult (ages 31 – 45)
an older adult (ages 46+)

diagnosed less than 1 year ago
diagnosed 1 – 3 years ago
diagnosed more than 3 years ago

is not in renal failure and not on dialysis
is starting dialysis in the near future
is on dialysis
is a transplant recipient

2. Would you like to be matched with a family member/loved one of a person with a Alport Syndrome?
No Yes

Male Female

a spouse
a parent
a sibling
an extended family member
a mentee, significant other, or close friend

diagnosed less than 1 year ago
diagnosed 1 – 3 years ago
diagnosed more than 3 years ago

is not in renal failure and not on dialysis
is starting dialysis in the near future
is on dialysis
is a transplant recipient

3. Please list any factors that might make it difficult for you to work with a particular type of mentor.


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