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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 one virtual 4-hour training session. Are you willing/able to attend a training session? *This question is required.

Availability

Please provide one professional reference

6. 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

7. Professional Reference (Can be a leader or a colleague) *This question is required.

First Name

Last Name

What is their relationship to you?

Email Address

Phone Number