Peer Support Therapy Consent Form
Use this form to join peer support therapy, share basic contact and scheduling details, and acknowledge the peer support consent terms.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Peer Support Session Details
Preferred Session Format
*
In-person
Virtual
Either
General Availability
*
Goals or Topics for Support
Emergency Contact and Consent
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consent Acknowledgment
*
I understand peer support is non-clinical and voluntary, and I agree to participate under the program's guidelines
Submit
Should be Empty: