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Peer to Peer Interest Form
This class is for people living with a mental health condition, ages 18 years and older. All information gathered in this form will be kept strictly confidential and will not be shared with any third party or person.
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* Indicates required question
First & Last Name
*
Your answer
Preferred Phone Number
*
Format ###-###-####
Your answer
Email
*
Your answer
Street, City & Zip Code
Your answer
Your Age
*
Your answer
Type of mental health diagnosis or symptoms
*
ADHD
Anxiety Disorder
Bipolar Disorder
Borderline Personality Disorder
Depression
Dissociative Disorder
Obsessive-Compulsive Disorder
Post-traumatic Stress Disorder
Schizoaffective Disorder
Schizophrenia
Unknown
Other:
Required
How long has it been since you were first symptomatic?
*
Approximate length of time
Your answer
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