• PPMNY Mentee Intake Questionnaire

  • Thank you for your interest in the Plant Powered Lifestyle Mentorship program with Plant Powered Metro New York! Please answer the following questions so we can make a good-fit match to support your transition to a whole food, plant-based (WFPB) lifestyle.

    At this time, PPMNY provides mentorship only to residents of the New York metropolitan area, defined as New York City, Long Island, and surrounding counties. If you have any questions about your eligibility, contact mentorship@ppmny.org.

    Mentorship is intended to focus on aspects of lifestyle that make healthy eating possible; please continue to direct your medical and nutritional questions to licensed practitioners. In most cases, PPMNY's volunteer mentors are not licensed medical providers or registered dietitians but instead average people who have made a commitment to a plant-powered lifestyle. Under no circumstance should individuals receiving mentorship forgo standard medical care, especially if you have a diagnosed illness. Anyone currently on medication is required to simultaneously work with your medical provider(s) throughout the dietary change process to adjust medications accordingly. This form includes a waiver that must be completed before proceeding with mentorship.

  • Are you based in the New York metro area (NYC, Long Island, surrounding counties)?*

  • We appreciate your interest in PPMNY's mentorship program, but it appears you aren't eligible. At this time, PPMNY is able to provide mentors only to residents of the New York metro area. If you don't know whether you're eligible, contact mentorship@ppmny.org for clarification.

  • Format: (000) 000-0000.
  • Where in the New York metropolitan area do you live?*
  • When is your birth year?*
  • Which of the following best describes your race? Choose any that you identify as.*

  • My Motivation, Eating Habits, & Skills

  • What are your personal barriers to adopting whole food, plant-based nutrition? (Check any that apply)*
  • Which option best describes how you currently eat?*
  • What are your dietary change goals for mentorship? Please check any statements that apply.*
  • How comfortable are you with preparing your own meals?*
  • Do you need help with any of the following? Check any that apply.*

  • Mentorship Logistics

  • How would you prefer to communicate with your mentor? (Check any that apply)*
  • What times of the week would you prefer to communicate with your mentor?*
  • How frequently would you like to interact with your mentor?*
  • Depending on availability and cost, would you be interested in future intensive jumpstart programs offered by PPMNY? Jumpstarts offer support for a complete dietary transition in a short period of time, usually between 10-30 days, and mentorship is provided.*

  • Waiver and Liability Release for Mentees in PPMNY's Lifestyle Mentorship Program

  • All mentees in the Lifestyle Mentorship program are required to electronically sign the following waiver and liability release:
  • Today's date:*
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    2 digit month, 2 digit day, 4 digit year
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