JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
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 via email.
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.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
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
Time Zone:
*
Choose
Alaska (AKST)
Central (CST)
Eastern (EST)
Hawaii (HST)
Mountain (MST )
Pacific (PST)
Other
Country:
*
Your answer
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
Are you willing to stay on as a Mentor after your 6-month term with your assigned Peer is complete?
Choose
No
Yes
Undecided
Are you interested in mentoring multiple Peers at once?
Choose
No
Yes
Undecided
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.
To which gender identity do you most identify:
*
Choose
Female
Male
Non Binary
Prefer to self describe below:
Pronouns (e.g. "they/them/theirs" or she/her/hers" or "he/him/his"):
*
Your answer
Race/Ethnicity:
Choose
American Indian or Alaskan Native
Asian
African American
Caucasian
Hispanic
From Multiple Races
Native Hawaiian or other Pacific Islander
Prefer not to answer
Marital Status:
Choose
Divorced
Domestic Partner
Married
In a Relationship
Separated
Single
Widow
Other
To what extent does religion play a role in your life:
Choose
Significant / very important role
Practice religion, but not a very significant role
Not religious
Other
If you selected 'other' above, please describe:
Your answer
Are you bilingual:
Choose
No
Yes
If yes, please list what language(s):
Your answer
How many children do you have:
Choose
0
1
2
3
4
5+
What are their ages: (check all that apply)
Child 1
Child 2
Child 3
Child 4+
0 - 3 months
3 - 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
Child 1
Child 2
Child 3
Child 4+
0 - 3 months
3 - 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
Clear selection
Are you or your partner currently pregnant:
Choose
No
Yes
If yes, what is the due date:
MM
/
DD
/
YYYY
Are you a parent of multiples:
Choose
No
Yes - Twins
Yes - Triples
Yes - Four or more
Did you or your partner experience pregnancy or post birth health complications:
Choose
No
Yes
If you selected yes above, please describe:
Your answer
Do you identify as a NICU parent:
Choose
No
Yes
Did you or your partner go through infertility treatments:
Choose
No
Yes
Have you or your partner suffered a pregnancy or infant loss:
Choose
No
Yes - pregnancy loss
Yes - loss of an infant
Yes - loss of a multiple
Yes - Ectopic
Yes - Stillbirth
Yes - multiple losses
Have you ever served or are currently serving in the Armed Forces (U.S. Military):
Choose
No
Yes - I have served
Yes - I am currently serving
I do not live in the United States
If yes, which Branch:
Choose
Air Force
Army
Coast Guard
Marine Corps
Navy
Reserves
Other
Are you a military dependent (spouse):
Choose
No
Yes
If yes, which Branch:
Choose
Air Force
Army
Coast Guard
Marine Corps
Navy
Reserves
Other
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:
Choose
Yes
No
Not sure
If yes, which PMD(s) were you affected by: (please check all that apply)
Postpartum Anxiety (PPA)
Postpartum Bipolar Disorder
Postpartum Depression (PPD)
Postpartum OCD (PPOCD)
Postpartum PTSD (PPPTSD)
Postpartum Psychosis (PPP)
Postpartum Rage
I am not sure
Other
If you selected 'other' above, please describe:
Your answer
Did you experience any of the following symptoms when you had your PMD(s): (please check all that apply)
Intrusive Thoughts
Suicidal Thoughts
Insomnia
Panic Attacks
Other
If you selected other above, please describe:
Your answer
If you did suffer with a PMD, where are you in your recovery process:
Choose
Beginning of my recovery
Middle of my recovery
Almost fully recovered
Fully recovered
I'm not sure
I did not suffer with a PMAD
Other
If you have fully recovered, how long have you been recovered:
Choose
0 - 6 months
6 - 11 months
1 year
2 years
3 years
4 years
5+ years
N/A
Did you use medication as a part of your recovery:
Choose
Yes
No
I prefer not to answer
Did you see a therapist/counselor as part of your recovery:
Choose
Yes
No
I prefer not to answer
During your PMD treatment, did you participate in any of the following programs: (check all that apply)
Inpatient Care
Partial Hospitalization
Intensive Outpatient (IOP)
I did not participate in a program
Other
If you selected other above, please describe:
Your answer
Did you use any of PSI's resources when you were going through your PMD: (check all that apply)
I called/texted PSI's Helpline
I spoke with my local PSI Coordinator to find resources in my area
I attended PSI's virtual Online Support Group Meetings
I called in for PSI's Chat with an Expert
I joined PSI's private Facebook group
I joined PSI's Smart Patients Postpartum Community
I browsed PSI's website
I was not aware of PSI when I was going through my PMD
Other
If you selected other above, please describe:
Your answer
Did you or your partner breastfeed, formula feed or tube feed:
Choose
Breastfeed
Formula feed
Both (Breast and Formula)
Tube feed
Other
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:
*
Choose
Yes
No
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
What do you hope your Peer will gain through this process:
*
Your answer
With your current time commitments, are you able to dedicate at least 1 hour a week to your Peer? This time will be spread between phone calls, text messaging and possible online meetings:
*
Choose
Yes
No
I need more information
Are you willing to communicate via texting or phone calls with your Peer at least ONCE per week:
*
Choose
Yes
No
I need more information
Do you currently lead or facilitate an in-person or online support group:
*
Choose
Yes
No
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
Do you consider yourself to be more of an Extrovert or an Introvert?
Extrovert
Introvert
a little of both
I'm not sure
Clear selection
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)
*
Yes
No
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:
*
Yes
No
I agree to participate in phone calls and respond to text messages from my Peer in a timely manner:
*
Yes
No
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)
*
Yes
No
I understand that submitting this application does not guarantee I will be selected for the PSI Mentor Program:
*
Yes
No
Thank you
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Postpartum Support International.
Report Abuse
Forms
