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Peer Support Patient and Family Interest Form

Thank you for you interest in becoming a Peer Supporter! Please tell us more about your experience by completing this form. Someone from the Betsy Lehman Center will be in touch with you.
1. Contact Information
This question requires a valid email address.
Your preference for us to contact you?
3. Age *This question is required.
4. Race/Ethnicity 
Peer Support Experience 
7. Have you or a family member ever experienced an unanticipated outcome or medical error while receiving care? 
(By “unanticipated outcome” we mean any outcome, whether from medical error or not, that differs significantly from the desired outcome of care)
  *This question is required.
8. Have you had experience providing peer support?    *This question is required.
11. How many hours a month are you available to volunteer? *This question is required.
12. Are you available for an in-person meeting at the Betsy Lehman Center in Boston to introduce yourself? *This question is required.
13. Would you be able to do a video meeting?  *This question is required.
13. The Peer Support Program will require all supporters to attend two separate 3-hour training sessions. Are you willing/able to attend the needed training sessions?   *This question is required.
14. Professional Reference  *This question is required.
15. Personal Reference (This should be an adult not related to you that you have known for at least 3 years)  *This question is required.