Connecting Hearts
Peer Support Program
Participant Intake Form
Name
*
Address
*
Phone Number
*
E mail Address
*
example@example.com
Do you prefer to be contacted by text, phone call or email?
*
Current Diagnosis and Treatment
Support System
Self Care Practices
What are you looking for from a peer supporter?
What wellness services are you interested in? Check all that apply.
Yoga
Reiki
Support group
Counseling
Sound Healing
Facials
Tai Chi
Meditation
Crystal Healing
Polarity Therapy
What time of day are you most available ?
*
What else would you like us to know about you and your life?
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