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Senior Peer Counseling Application

Please complete all the fields below and submit online



Mailing Address*

Email Address*

Are you 55 years or older?*

Enter today's date*

How did you hear about this program?*

What are some of concerns/problems older people experience?*

What do you think are some of the positive things about growing older?*

How do you feel about your own aging process?*

Why are you interested in participating in the program?*

How do you imagine participation in Senior Peer Counseling could influence your personal life?*

In what way do you believe one’s behavior and attitudes have an effect on one’s health?*

What qualities help one become an effective peer counselor?*

Describe any experience you have with counseling or health education.*

Describe some of your previous employment/volunteer activities.*

Please explain any health problems that would limit your involvement in the program or might help you understand another’s situation better.*

What form of transportation would you be using?*

What else would you like us to know about you?

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