Peer Support and Individual Consultation Request Form

Name *

First

Last

Organization (if any)

Email *

Phone *

I am a... *

Person seeking support for myself
Family member of someone I am seeking to support better
Service provider (peer supporter, clinician, crisis worker, nurse, doctor, etc)
Organization seeking consult for a team or people in leadership roles

I am located... *

In Western Massachusetts
Outside of Western Massachusets

Note: If you are an individual seeking support in Western Mass, you get one free session. You are also welcome to connect with our advocates at no cost through our centers, bridging, peer respite, or other offerings.

My Time Zone

Please tell us a little about what you are looking for *

This helps us decide who to connect you with.

Support Sessions are generally held on Zoom or Google Meet. Does this work for you or would you?

Zoom or Google Meet works for me
I prefer a phone call
I would like to meet in person if possible (WMass only)
Other

Is there anyone particular on our team who you are hoping to talk to? (optional)

When are some good times in the next week or two for us to call or meet with you? *

How would you like us to respond to schedule with you? *

Text
Phone Call
Email