• Peer Support Referral Form

    Peer Support Referral Form

    Please fill out the secure Peer Support Referral Form if you are interested in receiving Peer Support Services with our organization. After you complete the referral form, our team will review all the information and will reach out to the individual through the contact method provided.

  • What is Peer Support?

    Peer support is a voluntary, person-centered service provided by people with lived experience of mental health and/or substance use and recovery. Peer Support Specialists walk alongside individuals, helping them identify their strengths, explore goals, connect with resources, and define their own path to recovery and wellness.

     

    Service Availability:

    Our services are available in Multnomah, Clackamas, and Washington counties.

    We support people who are navigating substance use or are in recovery from addiction. At this time, we do not offer open-referral peer support services specifically for mental health needs alone.

    Our services are free, and you do not need health insurance to participate.

  • Today's Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Who is filling out this referral form:*

  • Voice & Choice

    Thank you for taking the time to support this person by helping with their referral.

    We want to make sure the person receiving services has the opportunity to share what matters to them, make their own choices, and identify the goals they would like to explore. This focus on voice and choice is an important part of Peer Support.

    Because this referral is centered on the person’s own goals, preferences, and experiences, we ask that they be present and involved when the form is completed. If they aren’t available right now, please come back to it together when they’re able to participate.

    Thank you for helping us make sure their voice is at the center of the referral.

    • General Participant Information 
    • Birthdate:*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Gender Identity:*
    • Race / Ethnicity:*
    • Participant Support Needs & Preferences 
    • What county would you like to receive services?*
    • What type of support are you looking for? (Please select the option that best describes your needs)*
    • Peer Support Language Preference*
    • If possible, would you like us to match you with a Peer Support with lived experience of any of the following?
    • Contact Information 
    • What is the best way for us to make initial contact with you? (single choice)*
    • Format: (000) 000-0000.
    • Referring Partner Information  

    • Working Together to Support the People We Serve

      Collaboration helps us stay connected and work together to provide the best possible support for the people we serve. With permission, we may connect with you when needed to support coordination.
    • Format: (000) 000-0000.
  • Should be Empty: