Best Now
Peer to Peer Counseling
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Email
*
example@example.com
Employment
*
Please Select
Employed
Unemployed
Disabled
Retired
Student
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Preferred Method of Contact
*
E-mail
Home Phone
Cell Phone
Mental Health Information
Tell us more about yourself
Briefly describe why you are seeking Peer-to-Peer Counseling support and what you hope to achieve through the counseling sessions.
*
Are you currently receiving any other mental health or support services? If yes, please specify.
*
Medical History
Are you currently taking prescription medication?
Yes
No
Do you use tobacco?
No
Daily
Weekly
Less
Former User
Do you use alcohol?
No
Daily
Weekly
Less
Former User
Caffeine use?
No
Daily
Weekly
Less
Former User
Have you been convicted of drug related charges?
Yes
No
Please explain the circumstances
Mental Health History
Have you previously received counseling or therapy services? If yes, please provide a brief overview of your previous experiences.
*
Therapist Name
First Name
Last Name
What specific topics or areas would you like to focus on in your Peer-to-Peer Counseling sessions?
*
Stress management
Coping strategies
Relationships
Self-esteem
Other
Do you have any preferences or requirements for the Peer Support Specialist you will be paired with? (e.g., similar lived experience, specific cultural or language preferences)
*
Is there any additional information you would like to share that you believe would be helpful for us to know in matching you with a suitable Peer Support Specialist?
Reason for seeking help
Average hours of sleep per night
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
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