Ohio Peer Recovery Supporter Reference Form - Mental Health America of Ohio

Name of Applicant*
First Last
Name of person completing this form*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Describe the strengths and assets the applicant would offer as a Peer Recovery Supporter:
How well does the applicant interact with others?*
Do you have any concerns about this person becoming a Peer Recovery Supporter?*
I verify I have given true, accurate, and complete information on this form to the best of my knowledge. My typed name below represents my signature on this application:*

Call or text the Suicide and Crisis Lifeline at 988

Office Address
2323 W 5th Ave, Suite 160
Columbus, OH 43204