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Peer Mentorship Interest Form
Are you an individual experiencing mental health challenges? By filling out this form, you are indicating an interest in working 1-on-1 with a Peer Mentor. A Peer Mentor will help guide you in creating a wellness plan and help you towards steps in reaching your goals in mental health recovery. ________________________________________________________________________________________Spots are limited, NAMI is able to match 16 mentee applicants with a mentor. Your application will be reviewed and you will be notified whether you were matched with a peer mentor or other program resources that are available to suit your needs. Thank you for your interest in the PRSS mentorship program!
Would you like this form in spanish? (¿Quieres este formulario en español?)
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Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
How did you hear about us?
Please Select one
Google or another internet search
Word of Mouth
Other (Please specify...)
Other
Please tell us a little bit about you, your needs/goals, and what you hope to accomplish with a Peer Mentor:
*
What qualities, characteristics or experiences are you looking for and prefer in a Peer Mentor?
*
By Submitting this form you're giving NAMI Southern Nevada to subscribe you to our monthly newsletter as well as contact you via email or phone when an opening with a Peer Mentor becomes available. Do you consent?
*
Yes
Add me to the waitlist only
I've changed my mind, just add me to the newsletter (this will NOT add you to our waitlist)
No
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