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3 O’Clock Coffee Club – Participant Intake Form

A confidential peer support connection through Hope’s House

🧍‍♂️SECTION 1: Contact Information

First Name

Last Name (Optional)

Alias/Nickname (if preffered)

Phone Number

Email Address

Preffered Contact Method (select all that apply)

Preffered Contact Method (select all that apply)

🧠SECTION 2: Support Background

What is your connection to the first responder community?

Are you seeking support for yourself or on behalf of someone else?

Are you seeking support for yourself or on behalf of someone else?
A
B

Is there anything you’d like us to know before we connect you?

📋SECTION 3: Preferences

Would you prefer to speak with someone who has lived experience as (select all that apply)

Would you prefer to speak with someone who has lived experience as (select all that apply)

Are there any days/times you are generally unavailable?

Is there a specific peer support volunteer you’d like to request?

You can view available peer volunteers at hopeshouse.life/coffeeclub. We’ll do our best to honor your request based on availability

🛡️SECTION 4: Confidentiality & Safety

All information submitted is kept strictly confidential and will only be shared with the assigned peer support volunteer and program leadership as needed. We are not a crisis line or clinical mental health provider.

If you are in immediate danger or need urgent support, please call 911 or the Suicide & Crisis Lifeline at 988.
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❤️SECTION 5: Emergency Contact (Optional but Encouraged)

Emergency Contact Name

Relationship to You

Phone Number

This is only used in the event of a safety concern and never shared beyond our leadership team.

✅SECTION 6: Submission & Next Steps

Thank you for reaching out. Once submitted, our team will match you with a peer support volunteer who best fits your background and preferences. You’ll hear from them soon.
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