Teen Peer Counselor Volunteer Application

Name*

Address*

Phone*

Email*

Birthday*

MM

DD

YYYY

Age*

School Name*

Year In School*

Have you ever been convicted of a crime?*

Yes
No

If yes to above question, please explain.*

Please list any food allergies or dietary restrictions and severity.

How did you hear about Teen Lifeline?*

Name of Parent/Guardian*

Email of Parent/Guardian*

Person to notify in case of emergency*

Relationship to you?*

Phone Number*

Address*

Do you have available time to be a peer counselor?*

Yes
No

Briefly list your hobbies or interests?*

List any afterschool commitments or responsibilities you have (work, family, sports, clubs, etc.)*

Briefly explain your interest or motivation in becoming a peer counselor.*

What problems are teens facing today? How can Teen Lifeline help?*

Can you realistically make a commitment to Teen Lifeline?*

Yes
No

Have you had any experience with counseling before? Please describe.*

How would you respond to a 15 year old girl who was having a problem with her boyfriend? Lately he doesn't seem to be interested in her, she feels shut out, alone and confused. She doesn't know what to do.*

What is the role of a peer counselor?*

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Teen Peer Counselor Volunteer Application

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