Peer Counselor Request Form Name:(required) Phone Number:(required) Email:(required) Best way to be contacted:(required) Email Phone How soon are you looking to meet with someone? Which type of Peer Counselor do you want to meet with?(required) Individual Peer Counselor Family Peer Counselor What is your (or your loved one's) diagnosis? Relationship to person with diagnosis (if not yourself)? Preferred days/times Do you have any preferences for you Peer Counselor: Male Female Older Younger Faith Based No preference Were you referred by someone?