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Request a mentor
Use the form below to request a one-to-one peer support mentor.
Please fill out the following information to get connected to our Keshet Parent & Family Connection a national mentoring and leadership program. We will be in touch within two weeks. We welcome participation from across the country.
All information will be kept strictly confidential.
Contact Information
Title
Please select...
Cantor
Dr.
Rabbi
Rev.
Prof.
First Name
Last Name
E-mail
Email Type
Please select...
Personal e-mail
Work e-mail
Phone Number
Phone Number Type
Please select...
Home phone
Work phone
Cell phone
Address
City / Town
State/Province/Region
Zip / Postal Code
Country
Please use discretion when contacting me.
If we call you, we will say it's in regard to your inquiry.
Peer mentors are available to speak with parents or family members of LGBTQ people or with LGBTQ people, themselves.
Please check either or both options.
I am a parent or family member of an LGBTQ person.
I am a LGBTQ individual.
About Your Family Member(s)
What is your relationship to the LGBTQ member of your family?
I am a:
Mother
Father
Parent
Aunt
Uncle
Grandparent
Sister
Brother
Sibling
Other (describe below)
How does your LGBTQ family member identify?
Gender
Woman (cisgender)
Man (cisgender)
Trans* man (FTM)
Trans* woman (MTF)
Genderqueer/Gender variant
Intersex
Other
Sexual Orientation
Bisexual
Gay
Lesbian
Queer
Straight
LGBQ
Other
How old is the person who is LGBTQ?
Please share any additional information we should know about your family member(s).
If you have multiple LGBT family members, we want to know about them! Please tell us about them here.
About You
How do you identify?
Gender
Man (cisgender)
Woman (cisgender)
Trans* man (FTM)
Trans* woman (MTF)
Genderqueer/Gender variant
Intersex
Other
Sexual Orientation
Bisexual
Gay
Lesbian
Queer
Straight
LGBQ
Other
How old are you?
What, if any, is your Jewish denominational affiliation?
Conservative
Orthodox (Haredi)
Orthodox (Modern)
Reconstructionist
Reform
Renewal
Secular/Secular Humanist
Unaffiliated
Other
Is there any other information that would be helpful for us to know?
Extra!
How did you find out about the Keshet Parent and Family Connection?
My synagogue
A rabbi
Another parent
Keshet website
A Keshet event
An event at my synagogue or other Jewish institution
A flyer
A palm card
Other (describe below)
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