Peer Network Membership Registration Form

Peers and Peer Specialists need your support more than ever! Join our regional peer network today to help us continue advancing peer support through the development and promotion of strong peer networks and leaders across Florida. As a member of the regional peer network, you will automatically be signed up as a member of Florida’s statewide peer network, the Peer Support Coalition of Florida (PSCFL).

You may notice that this membership form asks a lot of personal questions about your background. We apologize for asking such sensitive questions. We ask these questions for two very important reasons, (1) so we can better measure our impact in the state; and, (2) so we can provide our members with the best possible resources, information, and opportunities based on specific needs. We also ensure your information will be protected and not shared or sold.

* denotes required fields.

Contact Information

Personal  
Work  
Other
Cell  
Home  
Work

Peer Network & Peer Specialist Information

What is your CRPS certification status?* (check all that apply to you)
  
  
  
  
  

CRPS Designation(s): (check all that apply to you)

  
  
  
Yes   No  

Employment Information

Tell Us A Little More About Yourself

I am a: (check all that apply to you)

Gender

  
  
  

Sexual Orientation

  
  
  

Ethnicity

Are you of Hispanic Origin?

Race








Age

On your last birthday, what was your age group?
Under 16
16-24
25-34
35-44
45-54
55-64
65-4
75-84
85 & Over
Prefer not to say

Additional Information

Yes  
No  
Yes  
No  
Volunteer opportunities I’m interested in: (check all that apply)

Resources - help us to provide the best resources possible by completing this section

Are you looking for any resources? (check all that apply)

If you have any special requests or would like to provide us with additional information, please email us at membership@peersupportfl.org


Peer Support Coaltion of Florida, Inc.
© 2019 Peer Support Coalition of Florida