Peer Health Educator Session Scheduling 20/21

Wellness Coaching Intake Form

Peer Health Educators are available to provide support and guidance to all Skidmore students. PHE's are not therapists or psychologists and services may not be right for all students. If you believe that depression, anxiety, or other mental health disorders may be a factor for you, please visit the Skidmore Counseling Center.

The questions on this intake form will provide us with information about your reasons for seeking out a one-on-one conversation with a PHE as well as a preliminary sense of how suitable this service is given your needs. After you submit your form you will be contacted by email within 2 business days regarding next steps.

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* 1. What is your name?

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* 2. What is your Skidmore email address?

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* 3. What are your pronouns?

he/his

she/her

they/their

ze/zir

Other (please specify)

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* 4. What is your class year?

Senior

Junior

Sophomore

First Year

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* 5. In order for us to best match you with a Peer Health Educator, please provide some additional information about what topics you would like to discuss. Please check all that apply.

homesickness

time management

stress management

relationship issues

sleep issues

physical activity

nutrition

challenges transitioning to college

family stressors/obligations

financial organization/issues

self-confidence/self-esteem

academic performance

work-life balance

alcohol/other drug related issues

interpersonal difficulties

establishing healthy habits

general wellness

sexual and gender based misconduct

Other (please specify)

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* 6. Please tell us a bit about why you want to focus on the topics that you selected.

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* 7. Please indicate your general availability below. Your coach will be in touch to offer you time options that fit your preferences.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning (before 10am)	Morning (before 10am) Monday	Morning (before 10am) Tuesday	Morning (before 10am) Wednesday	Morning (before 10am) Thursday	Morning (before 10am) Friday	Morning (before 10am) Saturday	Morning (before 10am) Sunday
Late Morning (10-12)	Late Morning (10-12) Monday	Late Morning (10-12) Tuesday	Late Morning (10-12) Wednesday	Late Morning (10-12) Thursday	Late Morning (10-12) Friday	Late Morning (10-12) Saturday	Late Morning (10-12) Sunday
Early afternoon (12-2pm)	Early afternoon (12-2pm) Monday	Early afternoon (12-2pm) Tuesday	Early afternoon (12-2pm) Wednesday	Early afternoon (12-2pm) Thursday	Early afternoon (12-2pm) Friday	Early afternoon (12-2pm) Saturday	Early afternoon (12-2pm) Sunday
Afternoon (2pm - 5pm)	Afternoon (2pm - 5pm) Monday	Afternoon (2pm - 5pm) Tuesday	Afternoon (2pm - 5pm) Wednesday	Afternoon (2pm - 5pm) Thursday	Afternoon (2pm - 5pm) Friday	Afternoon (2pm - 5pm) Saturday	Afternoon (2pm - 5pm) Sunday
Evening (5pm - 8pm)	Evening (5pm - 8pm) Monday	Evening (5pm - 8pm) Tuesday	Evening (5pm - 8pm) Wednesday	Evening (5pm - 8pm) Thursday	Evening (5pm - 8pm) Friday	Evening (5pm - 8pm) Saturday	Evening (5pm - 8pm) Sunday

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* 8. If you have a preference for a specific PHE, please provide the name of the PHE who you would like to work with. Similarly, if there is a PHE who you would prefer not to be matched with, please share that information here.

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* 9. Would you like to be connected with a PHE who shares specific identities that you hold (ex/ class year, major, race, sexual orientation, gender identity, religion, etc)? If yes, please share information that will be helpful to us in matching you with a Peer Health Educator.

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* 1. What is your name?

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* 2. What is your Skidmore email address?

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* 3. What are your pronouns?

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* 4. What is your class year?

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* 5. In order for us to best match you with a Peer Health Educator, please provide some additional information about what topics you would like to discuss. Please check all that apply.

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* 6. Please tell us a bit about why you want to focus on the topics that you selected.

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* 7. Please indicate your general availability below. Your coach will be in touch to offer you time options that fit your preferences.

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* 8. If you have a preference for a specific PHE, please provide the name of the PHE who you would like to work with. Similarly, if there is a PHE who you would prefer not to be matched with, please share that information here.

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* 9. Would you like to be connected with a PHE who shares specific identities that you hold (ex/ class year, major, race, sexual orientation, gender identity, religion, etc)? If yes, please share information that will be helpful to us in matching you with a Peer Health Educator.

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* 10. Is there any additional information that you would like to share?