MENTOR 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 shortly. Sections of this application are OPTIONAL but are used to help us match our Mentors and Peers more accurately. We are grateful you are applying and look forward to learning more about you.
Email address *
First Name: *
Your answer
Last Name: *
Your answer
Best contact number: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Country: *
Your answer
Time Zone: *
Employer: (If any)
Your answer
Job Title: (If applicable)
Your answer
Birthdate: (MM/DD/YYYY) *
Your answer
How did you learn about the Peer Mentor Program:
Your answer
Demographics: (Optional)
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.
How would you describe your gender:
Race/Ethnicity:
Marital Status:
Are you bilingual:
If yes, please list what language(s):
Your answer
How many children do you have:
What are their ages: (check all that apply)
Child 1
Child 2
Child 3
Child 4+
0 - 6 months
6 - 12 months
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10+ years old
Are you or your partner currently pregnant:
If yes, what is the due date:
MM
/
DD
/
YYYY
Are you a parent of multiples:
Did you or your partner have pregnancy complications:
If you selected yes above, please describe:
Your answer
Do you identify as a NICU parent:
Did you or your partner go through infertility treatments:
Have you or your partner suffered a pregnancy or infant loss:
Have you ever served or are currently serving in the Armed Forces (U.S. Military):
If yes, which Branch:
Are you a military dependent (spouse):
If yes, which Branch:
PMD Information (Perinatal Mood Disorders)
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.
Are you a survivor of a PMD even if you have not been officially diagnosed:
If yes, which PMD(s) were you affected by: (please check all that apply)
If you selected other above, please describe:
Your answer
If you did suffer with a PMD, where are you in your recovery process:
If you have fully recovered, how long have you been recovered:
Did you use medication as a part of your recovery:
Did you see a therapist/counselor as part of your recovery:
Did you or your partner breastfeed, formula feed or tube feed:
Program Specific Questions (Required)
The following answers will further assist us in making appropriate Mentor/Peer matches. This section is required.
Have you ever been a Mentor before: *
If yes, with what organization and what year(s):
Your answer
Why do you want to become a Mentor with PSI: *
Your answer
What do you hope to gain personally from becoming a Mentor: *
Your answer
With your current time commitments, are you able to dedicate at least 30 minutes a week to your Peer? This time will be spread between phone calls, text messaging and possible online meetings: *
Are you willing to communicate via texting or phone calls with your Peer at least ONCE per week: *
Do you currently lead or facilitate an in-person or online support group: *
Are you comfortable working with a Peer in a different timezone than yours: *
Some Peers are further along in their recovery than others. Do you have a preference when it comes to your Peer: (preference is not guaranteed) *
Please list any other volunteer work you are currently involved with: (PSI State Coordinator, PTA, Softball Coach, etc.) *
Your answer
What do you like to do in your spare time: *
Your answer
Personality Quiz
In order to get to know you a little bit more, would you please complete this 3-minute online personality survey: (not required, but appreciated). **If you aren't sure how to answer a particular question, think of how you would have answered as a child.**
Please list the numbers you received for each category:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Choleric
Melancholic
Sanguine
Phlegmatic
Do you consider yourself to be more of an Extrovert or an Introvert?
Emergency Contact (Required)
Your privacy is as important to us as your emotional well-being. We do require an emergency contact #, but would only use it in a real or perceived emergency.
Name of Contact: *
Your answer
Phone #: *
Your answer
Relationship to you: *
Your answer
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 Peer in a timely manner: *
If selected as a Mentor, I agree to provide a two-week notice if I have to step away from the program: (this does not include emergencies) *
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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