Peer Application
Thank you for your interest in PSI's Peer Mentor Program. Please complete the following application and someone from our team will be in touch with you shortly. Sections of this application are OPTIONAL but are used to help us match our Mentors and Peers more accurately. We are grateful you are applying and look forward to learning more about you.
Email address *
First Name: *
Your answer
Last Name: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Country: *
Your answer
Time Zone: *
Best contact number: *
Your answer
Employer: (If any) *
Your answer
Job Title: (If applicable) *
Your answer
Birthdate: (MM/DD/YYYY) *
Your answer
How did you learn about the Peer Mentor Program:
Your answer
Demographics:
This section is OPTIONAL, but the information will help us make the best match between Mentor and Peer. This information will only be used by PSI and will never be shared with an outside source.
How would you describe your gender:
Race/Ethnicity:
Would you like to be paired with a Mentor of your same race and/or ethnicity: (we cannot guarantee this request)
Marital Status:
How many children do you have:
What are their ages: (check all that apply)
Child 1
Child 2
Child 3
Child 4+
0 - 6 months
6 - 12 months
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10+ years old
Are you or your partner currently pregnant:
If yes, when is the due date:
MM
/
DD
/
YYYY
Are you a parent of multiples:
Do you identify as a NICU parent:
Did you or your partner go through infertility treatments:
Have you or your partner suffered a pregnancy or infant loss:
Have you ever served or are you currently serving in the Armed Forces (U.S. Military):
If yes, which Branch:
Are you a military dependent (spouse):
If yes, which Branch:
Perinatal Mood Disorder Information
This section is OPTIONAL, but the information will help us make the best match between you and your Mentor. This information will only be used by PSI and will never be shared with an outside source.
Even if you have not been officially diagnosed, do you believe you are suffering from a Perinatal Mood Disorder (PMD):
If yes, which PMD(s) are you affected by: (please check all that apply)
If you selected 'other' above, please describe:
Your answer
If you are suffering with a PMD, where are you in your recovery process:
Do you currently use medication as a part of your recovery:
Do you currently see a therapist/counselor as part of your recovery:
Do/Did you or your partner breastfeed, formula feed or tube feed:
What do you like to do in your spare time:
Your answer
Do you consider yourself to be more of an Extrovert or an Introvert?
Program Specific Questions (Required)
The following answers will further assist us in making appropriate Mentor/Peer matches. This section is required.
What do you hope to gain from this program: *
Your answer
Is there a specific goal you would like to achieve while in the program: *
Your answer
What qualities would you like to see in a Mentor: (e.g.: good listener, empathetic, strong personality, etc.) *
Your answer
Emergency Contact
Your privacy is as important to us as your emotional well-being. We do require an emergency contact #, but would only use it for a real or perceived emergency.
Name of Contact: *
Your answer
Phone #: *
Your answer
Relationship to you: *
Your answer
I give PSI permission to contact the person listed above in the event of a crisis or emergency on my behalf: (whether an actual or perceived emergency) *
Application Agreement (Required)
By submitting this application, I certify that the information above is correct to the best of my knowledge.
I agree to follow the requirements and policies set forth by PSI's Peer Mentor Program: *
I agree to participate in phone calls and respond to text messages from my Mentor: *
I understand that submitting this application does not guarantee I will be selected for the PSI Mentor Program: *
Thank you
A copy of your responses will be emailed to the address you provided.
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