Peer Connection Request Form

Peer Connection Request Form

Please complete to form below to be connected with a certified peer mentor (someone with lived experience of addiction and recovery). Peers can help connect you to treatment, find the meeting that's right for you, and provide other recovery support. A peer will reach out within 24 hours of you completing this form. If you need immediate assistance, please call 9-1-1 or dial 800-923-4357 to reach Lines for Life's 24/7 Alcohol and Drug Helpline.
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What is your first name? *
What is your age? *
What is your gender identity? *
What is your race/ethnicity? *
What is your city of residence? *
What is your phone number? *
ex. (000) 000-0000
What is your email? *
How did you hear about this program?
i.e. Facebook, Google Search, a friend
Do you have any specific concerns you would like to address with a peer? (Optional)
Thank you for completing the form. A certified peer mentor will reach out within 24 hours. If you need immediate assistance, please call 9-1-1 or dial 800-923-4357 to reach Lines for Life's 24/7 Alcohol and Drug Helpline.
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