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Peer Support Patient and Family Interest Form

Thank you for you interest in becoming a Peer Supporter! Please tell us more about your experience by completing this form. Someone from the Betsy Lehman Center will be in touch with you.

1. Contact Information

First Name *This question is required.

Last Name *This question is required.

City/town

State

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Your preference for us to contact you?

Demographics

2. Gender *This question is required.

3. Age *This question is required.

18-24
25-34
35-44
45-54
55-64
65+

4. Race/Ethnicity

Black or African American
White
Asian
Hispanic/Latino
Some other race
Prefer not to respond

5. Primary language spoken

6. Other languages in which you are fluent (please list all)

Peer Support Experience

7. Have you or a family member ever experienced an unanticipated outcome or medical error while receiving care?
(By “unanticipated outcome” we mean any outcome, whether from medical error or not, that differs significantly from the desired outcome of care)
*This question is required.

8. If yes, please describe *This question is required.

8. When did this event occur? *This question is required.

8. Have you had experience providing peer support? *This question is required.

9. If yes, please describe *This question is required.

9. Why do you want to be a peer supporter? *This question is required.

10. What unique perspective either as a patient or caregiver would you bring to the Patient and Family Peer Support Network? *This question is required.

Availability

11. How many hours a month are you available to volunteer? *This question is required.

Less than 2 hours
2 hours
2-5 hours
5- 10 hours
10 hours or more

12. The Peer Support Program will require all supporters to attend a 4-hour training. Are you willing/able to attend the needed training sessions? *This question is required.

Reference

13. Professional or Personal (This should be an adult not related to you that you have known for at least 3 years) Reference *This question is required.

First Name

Last Name

What is their relationship to you?

Email Address

Phone Number