Peer Support Coalition

Initial Intake Form

Full Name *

Email *

Phone *

Address *

City *

State *

Country *

Postal code *

Date of birth *

Any Known Medical Conditions

Any Allergies?

Current Medications

Can You Describe What You're Looking for in a Certified Peer Specialist?

Are You Currently Being Seen by a Mental Health Provider?

Are You Comfortable With Us Speaking with Them?

If Yes, Please Leave their Name and Contact Information

Would You Be Interested in Individual or Group Support? Or Both?

Would You Prefer a Particular Gender(s) for Support?

Any Additional Comments, Questions Or Special Requests?

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