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Virtual Peer Support Network Interest Form

Thank you for you interest in becoming a peer supporter! Please tell us more about yourself and your experience by completing this form. Someone from the Betsy Lehman Center will be in touch with you.
1. Contact Information *This question is required.
2. Preferred method of communication
3. Gender *This question is required.
4. Race/Ethnicity (Check all that apply)
5. Do you speak any languages other than English?
6. Have you been trained to be a peer supporter? *This question is required.
When was your training?
The Peer Support Program will require you to attend a virtual 1.5 hours refresher training.  Are you willing/able to attend the training? *This question is required.
The Peer Support Program will require all supporters to attend one virtual 3-4 hour training session. Are you willing/able to attend a training session? *This question is required.
7. Do you have experience providing peer support? *This question is required.
In what capacity?
When was the last time you provided peer support?
Availability 
8. How many hours a month are you available to volunteer? *This question is required.
Please provide one professional reference
Professional Reference (If you are currently part of a peer support program at your organization, consider providing the contact information for the person who oversees the program) *This question is required.
Professional Reference (Can be a leader or a colleague)  *This question is required.
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