Peer2Peer Counseling interest form
Thank you for your interest in our Peer2Peer counseling program! Answer the questions below and we will match you with a Peer Support Specialist as soon as possible. Keep in mind when you are answering the questions regarding your counselor preferences that your preferences are not guaranteed to be given, however we will try our best to match you. Feel free to reach out to us with any specific questions concerns at Peer2peer@peerwellnesscollective.org

Here are some things to consider before signing up:
  • This service is free of charge.
  • You can meet with your peer counselor no more than once per week
  • You can work with your peer counselor for as short as one month or you can work with them for as long as 6 months. 
  • All peer counseling sessions are held online via google meet or zoom
  • Our Peer counselors program consist of both Certified Peer Support Specialists and Peer Support Specialist Interns. 
  • All of our Peer Support Specialist interns engage in weekly supervisions with a Certified Peer Support Specialist & Clinician to go over any questions that may arise during peer2peer sessions.
  • Peer2Peer counseling is not meant to be a substitute for therapy. If our peer counselor feels that you are better suited to be assisted by a therapist we will give you the option of a referral. 
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Email *
Legal First Name
Legal Last Name *
Nickname or Preferred Name *
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
City *
Zip Code *
County *
Phone Number *
4) Gender: (For Demographic data purposes only)
 *
Pronouns (he/him, they/them, she/her) *
5) Ethnicity: (For Demographic Data Purposes Only)
 *
Please provide us with the Full Name and Phone number of someone whom we can contact in case of emergency.  *
What is the reason you are seeking Peer2Peer Counseling services?  *
How would you describe the current challenges you are facing? *
Please list availability that you have to see a Peer counselor once a week. (Ex. Mondays I have open availability, Tuesdays not available, Wednesdays between 12pm and 4pm) *
Are you currently experiencing any thoughts of suicide? *
If you are currently experiencing thoughts of suicide please pause this application and contact the Suicide and Crisis Lifeline at 

988
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                                                       Counselor Preferences
Would you prefer a counselor who is: *
Would you prefer a counselor who identifies as: *
Required
Do you prefer for your counselor to speak another language that is not English: *
Required
If you selected other language not listed, please list the preferred language you are seeking. 
Is there any other relevant information we should know before submitting this interest form? *
A copy of your responses will be emailed to the address you provided.
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