SCI Peer Mentor Project Contact and Pre-Evaluation

Thank you for your interest in becoming a peer mentor for the SCI Peer Mentorship Program. Please complete this form and you will be contacted by a member of our team. All items that have a red asterisk (*) next to it means that the field is required to fill in to complete/submit this form.

Contact Information

Please fill out the following information

First Name

Last Name

Street address

City

State

Zip

Email Address

Phone Number (preferred)

2nd Phone Number

Preferred method of contact

Phone

The following questions will allow us to determine your eligibility to participate in the program and assist us with the peer mentor/mentee matching process. As a standard process for all volunteers at Good Shepherd Rehabilitation, we ask that you provide your date of birth so that we can complete a criminal background check. We also ask for 2 references. We will only contact your references and do a background check if you are eligible to participate in the program.

Please provide us with some background information so that we can match you with a mentee.

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Complete after learning more about the program

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