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
Email *
First Name: *
Last Name: *
Best contact number: *
Street Address: *
City: *
State: *
Zip Code: *
Country: *
Time Zone: *
Employer: (If any)
Job Title: (If applicable)
Birthdate: (MM/DD/YYYY) *
How did you learn about the Peer Mentor Program:
Are you willing to stay on as a Mentor after your 6-month term with your assigned Peer is complete?
Are you interested in mentoring multiple Peers at once?
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:
Race/Ethnicity:
Marital Status:
To what extent does religion play a role in your life:
If you selected 'other' above, please describe:
Are you bilingual:
If yes, please list what language(s):
How many children do you have:
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
Clear selection
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 experience pregnancy or post birth health complications:
If you selected yes above, please describe:
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:
Did you experience any of the following symptoms when you had your PMD(s): (please check all that apply)
If you selected other above, please describe:
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:
During your PMD treatment, did you participate in any of the following programs: (check all that apply)
If you selected other above, please describe:
Did you use any of PSI's resources when you were going through your PMD: (check all that apply)
If you selected other above, please describe:
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):
Why do you want to become a Mentor with PSI: *
What do you hope to gain personally from becoming a Mentor: *
What do you hope your Peer will gain through this process: *
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: *
Please list any other volunteer work you are currently involved with: (PSI State Coordinator, PTA, Softball Coach, etc.) *
What do you like to do in your spare time: *
Do you consider yourself to be more of an Extrovert or an Introvert?
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: *
Phone #: *
Relationship to you: *
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.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Postpartum Support International. Report Abuse