NAMI SMC Peer PALS Program- PAL Application
Please note that all of your answers will be held in strict confidence. Upon submitting your application, we will contact you for a virtual meeting, thank you!
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Email *
Date *
First and last name *
Address *
City *
Zip Code *
Phone *
Email *
How did you hear about the Peer PALS Program? *
Why are you interested in being a PAL? *
Have you completed the NAMI Peer to Peer Recovery Education program; the Peer Mentor program through the College of San Mateo, or do you have any other special training which might be useful for our program?  If YES, please describe. *
Please describe any experiences you have had working/helping others.         *
What are some of your favorite activities, hobbies or interests?   *
How do you rate how isolated you feel now? *
Not Isolated
Extremely Isolated
Some Peers are likely to want a PAL in their age range. With that in mind, we ask you to indicate your age range: *
Some Peers may also want a PAL who has the same, or similar diagnosis, thereby having a better understanding of what they're going through. With that in mind, please indicate your diagnosis (this is optional, but we want to make the best matches for our participants) *
Can you commit to the following job description and to a six-month match with your Peer? *
Because each individual is responsible for their own transportation, what kind of transportation will you use to meet up with your Peer? *
Are there any substance use issues that might influence your ability to work with a Peer? If, so how are you currently handling them? *
Do you smoke? *
How many days have you spent in the hospital or long term psychiatric facility in the past 5 years? *
How do you rate how you feel about your recovery or personal wellness journey? *
Not at all hopeful
Very hopeful
Did someone refer you? If so, please write their name.
Some Peer PALS prefer to meet virtually while others like to meet in person, or a combination of both. What is your preference?
Have you attended any mental health training and/or support groups, such as Menth Health First Aid, Peer to Peer, Connections Support Groups or other trainings? If yes, please indicate below.  *
Additional Information you would like us to know/comments:
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