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1-to-1 Peer Support Interest Form

Hello there! Thank you for your interest in LGBTQ Wellness' short-term 1-to-1 Peer Support services. Please fill out this form to connect with our staff to set up a consultation session.

The full guidelines for 1-to-1 peer support will be detailed at the bottom of this form, but here is brief overview of our scope of services:
  • LGBTQ Wellness can provide up to 6 sessions of 1-to-1 peer support per person. Each session can be up to 1 hour.
  • LGBTQ Wellness will reach out to the community member to have a consultation (20-30 minutes) before the 6 sessions begin.
  • The 6th and final session of 1-to-1 peer support will consist of identifying next steps and warm hand-offs if desired.
Take care!
1.Name
2.Pronouns
3.Email(Required.)
4.Age
5.How did you find out about this group?
6.What led you to exploring short term peer support?
7.Please read and agree to the terms and conditions of our short-term 1-to-1 peer support below:
  • LGBTQ Wellness can provide up to 6 sessions of 1-to-1 peer support per person.
    • Sessions will be between one community member and one LGBTQ Wellness staff member.
    • Each session will have a maximum duration of 1 hour.
    • Sessions will be spaced out based on the community member’s needs, but there will be a maximum of 2 sessions in one month spaced two weeks apart.
  • LGBTQ Wellness will reach out to the community member to have a consultation (20-30 minutes) before the 6 sessions begin. The consultation can be done through email, phone, or Zoom to go over the following:
    • Mandatory reporting
    • Scope of services
    • Goals for support
    • Possible additional resources
  • The sixth and last session of 1-to-1 peer support will consist of identifying next steps and warm hand-offs if desired. LGBTQ Wellness can provide the following during this session:
    • Referrals to community resources including additional peer support services
    • Referrals to clinician
(Required.)