Peer Support Survey 1. Basic InformationName: First Last Date: MM slash DD slash YYYY Email: What is your age group? 18-24 25-34 35-44 45+ How would you like to communicate with your peer support partner? (Select all that apply) In-person Phone calls Text messages Email Video chat When are you available to meet or chat with your peer support partner? Weekdays (Morning) Weekdays (Afternoon) Weekdays (Evening) Weeekend Flexible 2. Personal Interest & PreferencesWhich activities or topics interest you the most? (Select up to 3) Art & Crafts Music & Movies Sports & Fitness Reading & Writing Socializing & Making Firends Learning New Skills Mental Health & Welllness Other:Would you prefer to be matched with someone who shares your interest or someone different? Similar Interest Different interest No preference How do you prefer conversations to be? More structure with clear topics Casual and go with the flow A mix of both 3. Strengths & Areas for GrowthWhich best describes your role in peer support? I prefer providing guidance I prefer receiving support I like both equally What skills or strengths do you fell comfortable in? (Select up to 3) Problem-solving Giving advice Staying motivated Making friends/social skills Managing emotions Organization / time management Other:What would you like to improve or learn more about? (Select up to 3) Building confidence Handling stess Making friends/ social skills Managing emotions Setting & reaching goals Staying motivated Other:4. Communication & Support StyleHow do you like to receive encouragement? Verbal Praise Written messages Step-by-step guidance A mix of all three How outgoing are you? (Scale on 1-5) 1 (Very quiet) 2 (Somewhat quiet) 3 (Balanced) 4 (Somewhat talkative) 5 (Very talkative) Do you prefer a peer who is more talkative or more of a listener? More talkative More of a listener No preference 5. Goals for Peer SupportWhat do you hope to gain from this peer support program? (Select up to 2) Friendship & connection Emotional support Learning new skills Confidence in social situations Motivation & accountability Other:What qualities do you think make a good peer support partner? (Select u tp 2) Good listener Encouraging and positive Honest and direct Respectful of boundaries Willing to learn from others 6. Matching PreferencesWould you like to be matched with someone of a similar age? Yes, close to my age No, I'm open to any age No preference Would you prefer to be matched with someone who has similar challenges or different experiences? Similar challenge Different experiences No preference Is there anything else you'd like us to know to help find the best match for you?7. Peer Relationship Challenges & PreferencesHave you participated in a peer support program before? Yes, and it was a positive experience Yes, but it wasn't a good match for me No, this is my fisrt time If you've had a negative experience in peer support before, what were the main issues? (Select all that apply) Poor communication Mismatched personalities Lack of mutual effort Disrespect or boundary issues I have not had a negative experience Other:What challenges have you faced in past peer relationships? (Select all that apply) My peer wasn't reliable (missed meetings, didn't respond. etc.) We didn't have much in common They talked to much and didn't listen They expected me to solve their problems for them I didn't feel comfortable opening up No challenges What do you need from your peer support partner to feel comfortable? (Select all that apply) Clear boundaries and clear respect Reliable communication and follow-through Someone who listen and doesn't dominate the conversation A balance of giving and receiving support Someone who understands my challenges How do you prefer to handle disagreements or conflicts with a peer? Talk it through calmly Have a mediator (staff) help resolve it Avoid conflict and move on Other:If an issue arises with your peer match, how comfortable would you be letting staff know? Very comfortable Somewhat comfortable Not comfortable Do you have any concerns about being matched with a peer? (Open-ended response)
