Butterfly Baskets Peer Mentor Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in participating in the Butterfly Baskets Peer Support Program as a Peer Mentor. Please complete the application below and someone from our team will reach out to you to discuss the program.

Email *

Butterfly Baskets Peer Mentor Application

Name *

First and last name

Email *

Phone number *

Birthdate: *

YYYY

This program is currently only open to participants local to the Greater Philadelphia area. Please indicate which county you live in below.

Chester Couty

Montgomery County

Delaware County

Bucks County

Philadelphia County

Other:

Clear selection

Employer (if any):

Job Title (if applicable):

How did you hear about the Butterfly Baskets Peer Mentor Program?

Why do you want to be a Peer Support Mentor with Butterfly Baskets? *

With your current time availability, are you able to dedicate at least 30 minutes a week to your Partner (for 6 weeks)? This time may be spread between phone calls, text messages, and possible meetings (virtual or in-person, depending on safety and preference). *

Yes

Need more information

What do you hope to gain as a Peer Support Mentor? *

What do you hope your Peer Partner will gain through this program? *

Are you willing to reach out to your peer by phone or text message at least once a week? *

Yes

Maybe

Are you interested in supporting more than one Peer Partner at a time? *

Yes

Maybe

Please select the type of loss you have experienced. *

First Trimester Miscarriage

Second Trimester Miscarriage

Infertility

Stillbirth

Infant Loss

Other:

Required

How long has it been since your loss(es)? *

Do you have any living children? If so, please indicate how many and their current ages.

Are you or your partner currently pregnant?

Yes

Clear selection

Have you recovered from a Perinatal Mood Disorder? If yes, please check all that apply (whether or not you were officially diagnosed):

Postpartum Anxiety

Postpartum Depression

Postpartum Bipolar Disorder

Postpartum OCD

Postpartum PTSD

Postpartum Psychosis

Postpartum Rage

I am not sure

Other:

If yes, please share about your experience and recovery.

Have you ever participated in a Peer Support Program before?

Option 1

Yes, as a Peer Mentor

Yes, as an informal Peer Mentor (not part of a program)

If yes, please list the Peer Support Program and share about your experience.

Please share about any other volunteer work you do or other relevant activities and interests.

Personal Information and Demographics

The information provided below is requested to help us match Mentors and Partners. Feel free to skip any questions that you would prefer not to answer in this format.

Gender

Female

Male

Prefer not to say

Other:

Clear selection

Marital Status

Single

Married

Widowed

Divorced

Domestic Partnership

Other

Clear selection

Race/Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic

Native Hawaiian or Other Pacific Islander

White

Other:

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Butterfly Baskets Inc. Report Abuse

Forms