PIRS

Peer Support
Volunteer Application

Name:

Address:     [apt. #]:

Street:

Mailing Address:

City:     State:     Zip Code:

Home Phone Number: ()-

Work Phone Number: ()-

Disability::

Date/How Long:

Age:

Married/Single:     # of Years Married:

Children:   Age:

Native Language:    

Languages spoken other than English:

Occupation:

Educational Background: (including highest grade completed:)

Specific interests/hobbies:

Sports:

Member of any organizations:


Issues you feel comfortable discussing:

Vocational Educational Sexuality Issues
Caregiver Issues Sports/Recreation Relationship Issues
Money Issues Drug & Alcohol Suicide/Depression
ADL/Activities of Daily Living Anger  

(Those skills required for everyday functioning, such as transferring from bed to wheelchair, dressing, eating, getting in and out of a car or other skills for daily functioning relating to a Disability)

Are there any issues you do NOT feel comfortable discussing? (If so, please describe):


What Disabilities make you uncomfortable?:

None
Other
Multiple Disabilities
TBI
Speech Impediment

Times Available:

Days:  
Times:  

PLEASE FILL OUT THIS FORM, PRINT AND MAIL IT TO:

PEER SUPPORT VOLUNTEER
C/O Placer Independent Resource Services
11768 Atwood Rd. #29
Auburn, CA 95603