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Peer Support Intake Form

BCMHSUS Peer Support Program

To access peer support, please fill out this intake form and someone will contact you within 72 hours. All intake forms are strictly confidential and are only used for peer matching purposes. If you prefer, you may contact the Program Lead (Danielle Elder) at 778-847-6467 or elderdanielle8@gmail.com to leave a confidential voice, text or email message. 
1.First Name
2.Last Name (Full or Initial)
3.Preferred email
4.Preferred phone number
5.Preferred Method of contact  (Check all that apply)
6.Reason for reaching out (Check all that apply)
7.Are there any accommodations regarding peer support matching that you would like us to consider? Please check and specify.
8.Please identify which specialized area would you like to be connected with.