First Name
Last Name
Email
Phone Number
Gender
Male
Female
I'd rather not say
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
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1912
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Year
1980
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1984
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2009
2010
2011
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2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Is Jesus the only way
Yes
No
Maybe
How would you describe your relationship with Jesus? Please include spiritual practices.
What interests you about being a peer coach?
Briefly describe your personal mental health journey. This can include treatment or individual struggles with anxiety or depression. If you do not have a history of an individual struggle, that is okay. In this case, please explain how you maintained mental wellness.
Briefly describe your self care plan. How do you maintain your overall wellness. Please include healthy habits, routines, rhythms, and activities.
Are you able to maintain good boundaries? This includes not getting overly involved or enabling or harming the indivuals being served?
Yes
No
Unsure (please add details in last comment section)
Are you able to sit with someone that is hurting without trying to fix them or give advice?
Yes
No
Are you able to listen significantly more than you speak? 80/20 rule
Yes
No
What specific skills or areas of expertise would you like to contribute as a volunteer?
Are you comfortable working with individuals who may be experiencing mental health challenges?
Yes
No
Are you willing to undergo a background check as part of the volunteer application process?
Yes
No
Are you committed to attending future training?
Yes
No
Do you agree to maintain confidentiality and respect the privacy of individuals?
Yes
No
Do you agree to regular supervision to ensure everyone receives quality care?
Yes
No
Do you agree to follow procedures and policies presented? As the program develops, additional procedures may be added.
Yes
No
Do you agree to use the required forms, digital platforms, or others tools? (Additional support will be available if needed).
Yes
No
Do you agree that you will treat everyone with dignity and respect regardless of race, ethnicity, gender, socioeconomic status, disability, etc?
Yes
No
Have you attended or watched the recordings for all six weeks, including the homework assignments?
Yes
No
I will by next week
I understand that I will not be a professional counselor and I must operate within the scope of a helping peer. I understand that I will receive support, training, and supervision to ensure I am ready to serve.
Yes
No
Additional comments or concerns
Please provide the name and contact information for a personal reference. Preferred no family members.
Signature
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