Peer Support Referral Form
Please complete this form by clicking through the drop down sections below. Services provided are at no cost and no insurance is required. To learn more about MHAAO Peer Support Programs please visit our website at https://www.mhaoforegon.org
General Information
Today's Date
-
Month
-
Day
Year
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Alternate Phone Number
Preferred Method of Contact
i.e. phone or email
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Clackamas
Multnomah
Washington
Other
Are you currently housed?
Yes
No
Birthdate
*
-
Month
-
Day
Year
Date
Language Preference
*
English
Spanish
Other
Gender Identity
*
Woman
Man
Non-binary
Transgender Woman
Transgender Man
Agender
Prefer Not to Answer
Other
Pronouns
Ex: he/him, she/her, they/them, etc.
Race / Ethnicity
*
Alaskan Native
Asian
Black / African American
Hispanic, Latino/a/x
Native American
Native Hawaiian or Other Pacific Islander
White / Caucasian
Prefer Not to Answer / Unknown
Other
Service Preferences
Areas for Support (check all that apply)
*
Substance Use
Mental Health
Deflection
Type of Services Requested (check all that apply)
*
Peer Support
Health Screening (BHRN Only)
Harm Reduction
Preferred Gender of Peer Support Specialist
No Preference
Woman
Man
Trans or Non-Binary Person
Please describe the focus for support and what you're hoping we can help with:
If possible, would you like us to match you with a PSS/CRM with lived experience of any of the following?
Mental Health
Addiction
Criminal Justice System Involvement
DHS Child Welfare
LGBTQIA+
Veteran
Latinx/o/a Culturally Specific
Other
Referrer Information (if applicable)
Referrer Name
First Name
Last Name
Referrer Email
example@example.com
Referrer Phone Number
-
Area Code
Phone Number
Agency (if applicable)
Please indicate if this is a BHRN Partner referral
Yes
No
Unsure
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Submit
(Invisible Section Break) Archived Fields
Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Should be Empty: