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Virtual Peer Support Network - Volunteer 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.

First Name *This question is required.

Last Name *This question is required.

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Workplace/system

Department/specialty

Role

2. Gender *This question is required.

3. Race/Ethnicity (Check all that apply)

Black or African American
White
Asian
Hispanic/Latino
Other race
Prefer not to respond

4. Do you speak any languages other than English?

Which language(s)?

5. The Peer Support Program will require all supporters to attend 4-hours of training session (available as 1, 4-hr training or 2, 2-hr trainings). Are you willing/able to attend a training session? *This question is required.

6. Are you interested in becoming a Peer Supporter with the Virtual Peer Support Network (VPSN)? *This question is required.

Please provide one professional reference

7. 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.

First Name

Last Name

What is their relationship to you?

Email Address

Phone Number