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 via email.

Sections of this application are OPTIONAL but are used to help us match you with a Mentor more accurately. We look forward to learning more about you.
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Email *
First Name: *
Last Name: *
Best contact number: *
Street Address: *
City: *
State: *
Zip Code: *
Country: *
Time Zone: *
Employer: (If any) *
Job Title: (If applicable) *
Birthdate: (MM/DD/YYYY) *
To which gender do you most identify:
How did you learn about the Peer Mentor Program:
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.
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:
To what extent does religion play a role in your life:
If you selected 'other' above, please describe:
How many children do you have: *
What are their ages: *
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:
Did you or your partner experience pregnancy or post birth health complications:
If you selected yes above, please describe:
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:
Are you experiencing any of the following symptoms: (please check all that apply)
If you selected 'other' above, please describe:
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:
Are you currently or have you ever participated in any of the following programs: (check all that apply)
If you selected 'other' above, please describe:
Have you used any of PSI's resources: (check all that apply)
If you selected 'other' above, please describe:
Do/did you or your partner breastfeed, formula feed or tube feed:
What do/did you like to do in your spare time:
Do you consider yourself to be more of an Extrovert or an Introvert?
Clear selection
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: *
Is there a specific goal you would like to achieve while in the program: *
What qualities would you like to see in a Mentor: (e.g.: good listener, empathetic, strong personality, etc.) *
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: *
Phone #: *
Relationship to you: *
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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