Mental Health Buddy Match Form
Please fill out this form to be matched with a Mental Health Buddy.
Description of the Program:
The mental health buddy program is a mutual aid project facilitated by ATX Mental Health Fund that matches Austin area community members with each other to give and receive emotional support during the holiday season and beyond.
Mental Health Buddies will:
1. Check in with each other at least once a week.
2. Give space for their buddy to share their experiences.
3. Actively listen, validate, and provide support to your buddy.
4. Share your experiences and receive validation and support from your buddy.
You do not have to have any mental healthcare experience to be a mental health buddy. The program is open to individuals with a mental health diagnosis, and those without a mental health diagnosis. The program is completely free to participate in.
Criteria to Participate:
1. You live in the Austin area.
2. You would like a Mental Health Buddy.
3. You can commit to at least 3 months of communication with your buddy.
4. You have access to a reliable form of communication (phone/email)
Sign in to Google
to save your progress.
What is your name?
What is your phone number?
What is your email address?
What is your preferred method of contact?
What is your preferred language?
How many check ins would you like with your Mental Health Buddy every week?
Please tell us a little about yourself.
Please describe why you would like to participate in the Mental Health Buddy Program. How are you hoping to gain and give support through this experience?
The Mental Health Buddy Program is committed to being a safe and inclusive experience for all those that wish to participate. We ask that all our participants have a commitment to furthering social justice and actively dismantling racism, sexism, ableism, classism, homophobia and transphobia within ourselves and our community. Do you commit to uphold these values as a Mental Health Buddy?
Yes, I commit to uphold these values as a Mental Health Buddy.
Never submit passwords through Google Forms.
This form was created inside of UTmail.