Peer Support Space New Participant Form

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The following information is used on our end only for billing purposes, only answer what you feel comfortable sharing. Any information you do provide helps our services remain cost free to everyone, if you are comfortable sharing any of the below information it helps keep our resources accessible.

If you have any questions or need additional support please email Dandelion@PeerSupportSpace.org

** You only need to fill this out one time for any of our resources **

First Name *

Last Name *

Middle Name

Birthday *

YYYY

What Peer Support Space Resource Have You Used? (Check All That Apply)

Black LGBTQ+ Space

Butterfly Talks

Digital Communal Gatherings

Disability (is Not a Bad Word)

Hablemos Más

Hibiscus Club

Lotus

Metaphore Corner

Parenting While LGBTQ+

Peer-Led Autism Group

Planting Hope (Gardening Workshop)

Take Care of You

Your Black Matters

1 to 1 Support

Other:

Do you have Insurance? If so, what kind? *

Prefer not to disclose

I do not have insurance

Other:

Phone Number

Referral Source

Gender

Sexual Orientation

Race

Ethnicity

Do you have any Diagnoses? (Self-diagnosis is honored, share if comfortable elaborating)

Education

Zip Code

County

Housing Status

Houseless

Live Alone

Assisted Living Facility

Living With Relatives

Living With Non-Relatives

Other:

Clear selection

Marital Status

Primary Income Source *

Monthly Income *

Prefer Not to Answer

Other:

Days Worked in Last Month (Needed for Reporting Purposes Only)

Are you Disabled? (Elaborate if Comfortable)

Are You a Parent? (Step, Nontraditional is honored)

Yes

Clear selection

Household Size (# of People in Household) *

Prefer Not to Say

Other:

Annual Family Income (Estimates Okay)

Are You a Veteran?

Yes

Clear selection

Do you need support with drug use, alcohol, or any other substance? (If comfortable you can elaborate here)

Do you have a support person we have consent to contact in an emergency? Please list their name, number.

Is there anything else you'd like to share?

By completing this form, you are agreeing to the terms and conditions of using our services.

Things includes how to give feedback, file grievances, your rights as a participant, and a notice of privacy practices.

A full copy of the Terms and Conditions can be found at https://tinyurl.com/ypupxkve

Yes I agree

Other:

Clear selection

Signature *

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Submit

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