APPLY FOR PEER SUPPORT SERVICES

Arizona Problem Gambling Peer Support Program Application

Interested in Services? Apply now for free, confidential support from peers with lived experience. Help is just one step away.
Section A: Service Applicant Contact Details
Today's Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address
example@example.com
Best Time to Contact*

MorningAfternoonOther
Section B: Referral Source & Consent
How did you hear about this program?*

Arizona Department of Gaming WebsiteFriend/Family MemberHealthcare Provider/TherapistCommunity OrganizationBrochure/FlyerOnline SearchOther
If Community Organization, please specify the name
If Healthcare Provider/Therapist, please specify the name
This application form is for:*

MyselfReferring someone else
Name of Person Being Referred*
Your Relationship to Them*
Your Name*
Phone*
Please enter a valid phone number.
Section C: Service Preferences & Needs
What type of support are you most interested in?*

One-on-One Peer Support SessionsGroup Support MeetingsHelp with Resources (housing, employment, finances)Support for Family MembersNot sure - would like to discuss options
WHAT TO EXPECT & NEXT STEPS
1. We'll call you within 1 business day to schedule your first session.
2. Your Peer Specialist will contact you to introduce themselves and schedule an intake appointment

Your first session will cover:
- Your goals
- How we can help
- Setting up future meetings
This is your journey. Your specialist is here to support, not direct.
Should be Empty:

Arizona Problem Gambling Peer Support Program Application

Section A: Service Applicant Contact Details

Section B: Referral Source & Consent

Section C: Service Preferences & Needs

WHAT TO EXPECT & NEXT STEPS