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Glow Centre Peer Support Form
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Glow Centre for Sexual and Gender Diversity
Glow Centre Peer Support Form
Glow Centre Peer Support Form
2022-04-28T09:41:00-04:00
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Your Full Name
*
Email
*
Academic Term
Program
Appointment Time Slot (First choice)
Date
Time
Appointment Time Slot (Second choice)
Date
Time
Appointment Time Slot (Third choice)
Date
Time
I would like to receive racialized peer support
Yes
No
Glow Racialized Peer Support
Glow Peer Support Volunteer match
Two Spirit
Trans Man
Trans Woman
Nonbinary
Intersex
Genderqueer
Gay
Lesbian
Bisexual
Pansexual
Omnisexual
Asexual
Aromantic
Polyamorous
Other
Please Specify
Additional Details
Please feel free to include any additional details to aid in your request
Audio Only Support Session
Yes, I prefer an audio only support session
Although we prefer Video sessions as it helps us to connect with you on a more personal level, we also understand that there can be technical issues or other concerns where you may prefer an audio only session
Confidentiality
*
Yes, I accept
Everything you talk about in your Glow Centre Peer Support session will be kept confidential and we do not collect or store data; however, if you tell us or if we have reasons to believe that you are at the risk of harming yourself or others, we will have to break confidentiality and connect you with more professional support services immediately
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