MHFR Emotional/Peer Support Services
Thank you for your interest in our free emotional support services.

1. We will do our best to match you with a Mental Health First Responder® volunteer or mental health professional.
2. They will meet with you via a secure video call (Online) to process your anxiety, fears, and other concerns about the pandemic.
3. We are providing emotional support, peer support, and NOT Psychotherapy or Counseling.
4. This is a free service that the volunteer will coordinate with you.
5. This is short-term and limited.

PLEASE NOTE: Starting June 1, 2020

* If the volunteer deemed that you are needing a higher level of care, he/she will refer you to a licensed Counselor, Psychologist, or a Master Level Clinical Intern. Their services are NOT free but on a reduced cost or sliding scale.


WE HAVE A LONG WAITING LIST. IT MIGHT TAKE SOME TIME FOR US TO GET BACK TO YOU.

Email *
Informed Consent:
1. All information that you will share will be kept confidential– it means that whatever you will talk about with the first responder will stay between the two of you, in your chosen communication platform. However, if there is a danger posed regarding your safety or anyone you know, the first responder will disclose information that is needed to take action in order to protect you or someone else (i.e., making a police report for emergency cases).

2. You will be asked to choose a means of communication that is the most comfortable for you to use; hence it could be through phone call, or video call.

3. The volunteer first responders can communicate with clients for an hour per week and for follow-ups. Scheduling is based on the day and time of your availability and of the volunteer. You also can "take breaks," for example, in a specific week that the client does not want to engage in a conversation, it will be respected, as well as you can withdraw yourself from the service, anytime and at your comfort.

4. As stated above, this service is free and confidential. However, it is possible that the volunteer can transfer your case to a higher level of care, if you need to be seen by a licensed mental health professional - psychologist, counselor, etc.

5. Fees for the higher-level of care from the licensed psychologist or counselor is NOT free but could be adjusted according to your financial capacity.
Name (First and Last) *
Cell Number *
May we contact you via FB Messenger, Line, What's App? *
Required
If yes, what is your username so that we could send you an introduction message? If you said No, how could we get a hold of you? *
I am a *
I am needing *
I would like to received services from (Pls. ONLY Check one). *
What is your Occupation? *
I am willing to download an app for a secure video call with the MHFR volunteer or use my phone. We are using Doxy.me. Please sign up for a Doxy.me account - https://doxy.me/patients *
Doxy.me
Lately, I have been experiencing a lot of...... *
Is this related to? *
Required
I prefer to talk to a *
I need to talk to someone within... *
Your Age? *
Who referred you to us? *
What is your complete address? You will need to write it or we cannot assign a volunteer to you. This is for emergency and safety purposes. *
In case of emergency, whom should we contact? Pls. write down their name and contact telephone number. *
If you are a MINOR (17 y.o. and below) we need your guardian or parental consent. Pls. write their name, phone number and/or email. *
If the volunteer deemed that you are needing a higher level of care, he/she will refer you to a licensed Counselor, Psychologist, or a Master Level Clinical Intern. Their services are NOT free but on a reduced cost or sliding scale. *
I declare that the above information is true and accurate and consent to the service that I selected. *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Mental Health First Response.