Peer Support Form

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Connect with the DBTB Peer Support Team

Name

Email

Phone

Preferred Method of Contact

I would prefer a peer supporter who is...

Spouse/Common Law Partner of a DRPS Member

Dating/in a relationship with a DRPS Member

Parent of a DRPS Member

Child of a DRPS Member

Sibling of a DRPS Member

An Officer

A Civillian Member

It doesn't matter

I would prefer a peer supporter who understands...

The death or loss of a loved one

Marital separation and/or divorce

Infedility in a relationship

Relationships with physical, verbal, or emotional abuse

Traumatic pregnancy complication

Supported someone through a critical incident

Suicide or attempted suicide

Addiction

Compulsive behaviours

Physical, verbal, and emotional abuse

Currently dealing with a mental health disorder

Family member who is dealing with a mental health disorder

Caregiver of someone who is suffering from a medical condition

Family stress

Parenting Stress

Prefer not to say

Other

If other, please explain

Is there anything else you would like to share?

I agree to the Code of Conduct

I agree to theConfidentiality Policy

Submitted

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