ODEMSA Peer Support Team Application

Old Dominion EMS Alliance

Regional Peer Support Team Application
VISION: The Peer Support Team of the Old Dominion EMS Alliance (ODEMSA), Inc. functions to promote mental health awareness and education among public safety personnel, and to provide confidential peer support services to members of the ODEMSA region who experienced potentially traumatic events.

MISSION: The ODEMSA Peer Support Team encourages cooperation and coordination among the out-of-hospital and in-hospital resources which serve the 9,000 square mile region that encompasses Planning Districts 13, 14, 15, and 19 as defined by the Commonwealth of Virginia. The team will provide services at no cost to agencies as requested.

Click/Tap "Next" to continue

Document Upload

Please attach a copy of your credential(s) and/or certificate(s) based on the previous page's selection(s).
Emergency Medical Responder *
Emergency Medical Technician *
Advanced EMT *
Intermediate *
Paramedic *
Fire Fighter *
Dispatcher *
Law Enforcement Officer *
Nurse *
Doctor of Medicine (MD, DO) *
Licensed Clinical Psychiatrist *
Licensed Clinical Psychologist (Virginia) *
Licensed Clinical Social Worker (Virginia) *
Licensed Professional Counsellor *
Other *

Browse Files
Note: You may select multiple files to upload buy clicking "Browse Files" after each upload. Cancel of

COVID-19 Vaccine Status

Due to the nature of being a Peer Support member, all members must have received a full round of COVID-19 vaccination(s) or have a medical or religious exemption on file.
Have you received a full round of the COVID-19 vaccine? *

Yes No
Please upload proof of your vaccination status. *

Browse Files

Cancel of
Do you have a medical or religious exemption? *

Yes - Medical Yes - Religious Yes - Both (Medical and Religious) No
Please explain your exemption. *
It appears that you have not received a vaccination nor do you have a medical or religious exemption.

Please contact Jessica Goodman at (804) 560-3300 extension 105 for further information.

Professional References

Please provide three professional references of which only one may be a current ODEMSA Peer Support Team Member. Your references should be persons who can vouch for your qualifications and provide insight into your work ethic, skills, strengths, and achievements.
Name (Reference 1) *

First Name Last Name
Phone Number (Reference 1) *

Area Code Phone Number
Email (Reference 1) *
example@example.com
Name (Reference 2) *

First Name Last Name
Phone Number (Reference 2) *

Area Code Phone Number
Email (Reference 2) *
example@example.com
Name (Reference 3) *

First Name Last Name
Phone Number (Reference 3) *

Area Code Phone Number
Email (Reference 3) *
example@example.com

Old Dominion EMS Alliance