ACHA Peer Support Request Form

Thank you for your interest in the Heart to Heart Peer Mentor program. Please complete all of the following form. Remember: if you need immediate assistance contact your healthcare provider or call 911. 


Please supply us with an emergency contact

By signing this form, I acknowledge that this confidential medical information (including name, age, diagnosis) pertaining to me may be released to ACHA's "Heart to Heart Peer Mentor" assigned to contact me. This information will be transmitted by ACHA staff to the Heart to Heart Peer Mentor and will be kept in their strictest confidence. I understand that there are a few circumstances which may limit the confidentiality between a Peer Mentor and myself. These circumstances are listed below:

  • Your health or personal safety is at risk
  • You are a threat to another individuals' health or safety
  • There is a disclosure of physical, sexual or emotional abuse or neglect, which involves a minor, an elderly individual, or a person with a disability.

I also understand that the role of the Heart to Heart Peer Mentor is to offer basic support, information and referral. Furthermore, I understand that the Heart to Heart Peer Mentor does not replace professional help, attempt to provide psychotherapy or take the place of a physician. I know that ACHA's Peer Mentors do not give medical advice, lend money or provide counseling. Finally, I am aware that this relationship is short term in nature, not to exceed three to six months.

Should an appropriate match not be available through ACHA's Heart to Heart program, you will be contacted by the Program Coordinator with other options for support. I have received and read ACHA's Heart to Heart program description and realize the following:

  • A Peer Mentor is not a therapeutic counselor
  • A Peer Mentor does not dispense medical advice
  • A Peer Mentor is not expected to be a member's main source of support

I will not act on any perceived medical advice from the Peer Mentor assigned to me without consulting my physician.

Peer Mentors cannot contact anyone under 18, if you wish to speak with a Peer Mentor, please provide your parent/legal guardian's contact information.