Initial Client Consultation

Initial Consultation Form

Thank you for your interest in seeking a peer support mentor with Lifelong Mentors! Lifelong Mentor's 3 Step model is designed to find the best match between your personal needs and an experienced peer supporter. Please fill out this initial consultation form as the first step to the peer support process! After receiving your submission, you will receive a confirmation email and we will be in touch with next steps!
Full Name *

First Name Last Name
Gender
Phone Number *

Area Code Phone Number
E-mail *
example@example.com
Are you comfortable meeting with your assigned mentor online (Via Zoom)?
Where did you hear about us?
Were you referred to a peer support program (e.g., by doctor, social worker, psychiatrist)?
What should we know about you as a person? Please include as much detail as possible in order for us to find a suitable peer mentor match.
Briefly, what is your understanding of peer support?
Who would make your ideal peer support mentor?
Please Check all that apply: Currently I am experiencing/ have experienced

Depressed Mood Excessive fear Lost or gained weight Racing thoughts Body image issues Not getting enough sleep Repetitive thoughts/ behaviors Unbearable tension Violent thoughts Work/ School Problems Relationship issues Panic Attacks Excessive worry Self-harm Thoughts of suicide Recent loss/ grief Feeling guilty or worthless Other
If you selected "other" to the question above please elaborate:
Additional Information/Comments You Would Like us to Know
LifeLong Mentors takes Privacy and Confidentiality of shared information seriously. All communications (including this form) and any information shared by you is kept in strict confidentiality at all times. Only under instances where they may be concern for threat to others or yourself (e.g., disclosure of suicidal thoughts), we are required to disclose information related to any concerns. Do you agree with this policy?
Should be Empty:

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Initial Consultation Form