Safer Space for BLM: Mental Health Peer Support Volunteer

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Preferred Contact Method

PhoneEmail

Pronouns

She / Her / HersHe / Him / HisThey / Them / TheirsOther

Are you a BIPOC?

Yes, I am BlackYes, I am a non-Black POCNoOther

Location: City and State

Professional Experience

Do you have previous volunteer experience?

YesNo

Have you completed trauma informed training?

YesNo

Describe your volunteer/work experience with URM (underrepresented minorities) or BIPOC communities.

Are you bilingual? If yes, please indicate language(s):

Do you have experience working with neurodiverse and/or neurodivergent individuals?

Yes, I have experience working with neurodiverse populations.Yes, I have experience working with both neurodiverse and neurodivergent populations.No

On-Site Support: Areas of Volunteer Interest

Set up the Safer Space tent at protest siteTransport supplies at protest siteBreakdown/Clean up at protest siteDistributing mental health resources & information on-siteOn-site peer support during protests (in personal-protective-equipment)Other

Off-Site Support: Areas of Volunteer Interest

For providing peer-to-peer support with individuals, will you need office space to conduct sessions?

Yes, I will need access to office space where I can conduct either virtual or in-person sessions.No, I have my own confidential space to use.

I understand that tear gas and other safety risk factors may be present during protests. I agree to provide and wear my own personal protective equipment (ex: goggles and a respirator/mask) and I consent to voluntarily participate at my own risk.

YesNo

Please indicate the shifts for which you are generally available to volunteer:

As an individual provider, I have the following questions about participation:

Safer Space for BLM

Agency Information

Individual Information