UCA WAVES Youth Needs Assessment and Peer-Support Group Sign-Up

What days of the week and times would work best for you to briefly chat with a UCA WAVES Youth Ambassador?

What would you like to get from a peer-support program? (Please select all that you would be interested in.)

If "Other", please specify:

How would you like to help your peers in the peer-support group? (Please select all that is applicable.)

Share my experiencesShare my knowledge and resourcesProvide emotional supportOther

For "Other", please specify:

If you were to participate in a parent peer support group, what size would you prefer?

3-5 people6-10 people11-15 people>15 people

How often would you like to meet with the group? (Note: UCA youth peer facilitators are planning to have alternating “on” and “off” sessions, where “on” sessions would have specified agendas and “off” would be simply informal hangouts.)

Once a weekEvery other weekOnce a monthEvery other month

How long would you like the group to meet?

What topics would you like to discuss? (Please check all that apply.)

For "Other", please specify:

We have written the following ground rules for the groups:

Treat others with respect.
Listen with an open mind and avoid interrupting others.
Share what you’re comfortable with sharing; there is no pressure to say anything you want to keep private.
This is a safe space, and we are here to listen without judgment.
Be accepting of each other’s differences.

What additional ground rules would you like for the peer-support groups?

Are you interested in serving as a group facilitator? (Our expert mentors would provide training for you; estimated time commitment will be 2-3 hours/week.)

YesMaybeNo

Participant Agreement

Mission and Vision

The mission of the UCA WAVES Youth Peer-to-Peer Support Groups will be to destigmatize mental health issues through genuine connection, support, and empowerment. Led by UCA Youth Ambassadors and advised by the UCA Clinical Scholars, the program will be a series of online meetings to create space for open, interactive, and empathic peer-to-peer engagement.

While not for therapeutic or educational purposes, the program will connect high school-age Asian Americans (or any high school-age Americans with interest in Asian American culture) with their peers and thus serve the broader vision of UCA WAVES: to build “a supportive and engaging community that fosters healthy and holistic development of our youths.”

The program works toward the mission of UCA WAVES: to raise awareness of cultural identity and mental health challenges among young Asian Americans, to develop community support and resources for youth mental health, to promote cultural sensitivity to psychological well-being and responses, and to encourage civic engagement in public policies to address mental health issues.

Structure

The support groups are meant for anyone who identifies as Chinese or Asian American (or any American with an interest in Asian American culture) and is of high school age (13-18 years old). UCA Youth Peer Support Group is not a substitute for treatment from professional resources. Because of safety reasons, we will not be able to include anyone currently in an active phase of mental illness; however, we encourage them to join us once they are receiving appropriate therapy and treatment and are stable.

We will begin with a single group that will remain open for people to join throughout the first three months. We will meet for one hour once every other week via Zoom. Each meeting will include brief introductions, a warmup activity, open time for group sharing, a guided meditation, and an overview of a topic presented from youth Mental Health First Aid.

After this initial open period, we will break off into smaller, closed groups, each led by 1-2 Youth Ambassadors. Each group will focus on a specific theme or activity that members propose and agree on.

“Ground Rules” and Expectations

Treat others with respect.
Listen with an open mind and avoid interrupting others.
Share what you are comfortable with sharing; there is no pressure to say anything that you wish to keep private.
This is a safe space, and we are here to listen without judgment.
Be accepting of each other’s differences.

Confidentiality

We strive to create a safe and confidential place. All information you share about yourself in the group will be kept confidential. Only with your written permission will information be released to anyone outside of the Youth Peer Support Group. If your parents have concerns or inquiries, they can reach out to us, and if appropriate, we will invite them to a conversation with both you and a Group facilitator; otherwise, we will ask them to respect your autonomy and privacy as well unless the information pertains to harm to any individual.

However, confidentiality may not apply if suicidal/self-harming thoughts/behaviors are disclosed or/and emotional, physical, or sexual abuse happening to the minor or if the information relates to imminent harm to an individual or if we are obliged to share the information under a court order. Confidentiality may not apply if the information relates to harm or potential harm to anyone past, present or future. While the UCA Youth Peer Support Group staff members may consult with a supervisor or with one another to decide an appropriate and effective way to protect your safety, all staff members are ethically bound to treat information shared in the support group confidentially.

All members of the Youth Peer Support Group should respect the confidentiality of information shared by other members. As a group member, if another member shares information that falls into the exceptions listed above, you may reach out to the Youth Peer Support group staff.

Liability Waiver

This waiver of liability includes any risk of attending peer support meetings or other services provided by UCA WAVES. Please see the detail below:

UCA WAVES Youth Peer Support Group attendees will understand that these services are not offered as a substitute for clinical mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. You should also understand that group facilitators are not acting as medical professionals.
You will understand and agree that you are fully responsible for your own well-being during UCA WAVES Youth Peer Support Group meetings, and subsequently, your choices and decisions.
You will understand that UCA WAVES Youth Peer Support Group facilitators will debrief with their mentors, who are mental health experts, so that they can best serve you. Only UCA WAVES staff and volunteers will hear about information learned during the group sessions unless the information falls within an exception. The communication of information gained during the support group will always be done confidentially respecting your privacy and integrity, and when possible, identifying information is removed.
You will also understand that all comments and ideas offered by group members or facilitators are solely for the purpose of building a supportive community. You will be able to give informed consent, and hereby give such consent to UCA WAVES staff to assist you in engaging with such a community. In emergency situations wherein we think it is in the interest of your well-being (such as in a mental health crisis), we may contact your parent/guardian to share relevant information.
You will have read and understood the participant agreement above.
You will have understood that the use of technology is not always secure and accept the risks of loss of confidentiality associated with the use of email, text, phone, Zoom and other technology.
You hereby release, waive, acquit and forever discharge your therapist/coach, any agents, successors, assigns, personal representatives, executors, heirs and employees from every claim, suit action, demand or right to compensation for damages claimed or that you may have arising out of your own acts or omissions or acts and omissions of UCA WAVES staff and volunteers as a result of any advice given otherwise resulting from the peer support relationship contemplated by this agreement. You further declare and represent that no promise, inducement or agreement not expressed in this agreement has been made.
UCA WAVES reserves the right to refuse access to the Youth Peer Support Group.

Emergency Information

In case of emergencies, please provide the following information.

Where are you planning to join the Zoom meeting(s) from? (Physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Who can we reach you locally in case of emergency? (Name, phone number of someone geographically close to you)

Participant and Parent/Guardian Consent

If you have not reached 18 years of age, please ask your parents to sign below:

Parent/Guardian name

First NameLast Name

Parent/Guardian email

example@example.com

Parent/Guardian phone number

Please enter a valid phone number.

By submitting this application, youth and parents agree that UCA IL and any other co-host organizations can use pictures at the event for the purpose of UCA programs-related promotion only. We really appreciate your support for our youth programs.

If the youth is younger than 18 years of age as of the day of sign-up for the events, the parent/guardian must sign here to authorize the child’s participation in the registered event and volunteer services. Thank you for your support.

Youth Participant Signaturee

Parent/Guardian Signature (if youth is under age 18)

Thank you so much for signing up! A UCA WAVES Youth Ambassador will reach out to you by phone soon.