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 *
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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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