Social Mentor Application
We want to know about you!

Complete this application and press submit.  You can also print the application by using the link at the bottom and bring it to the Counseling Center in the NSU Student Center 217 or mail to NSU Social Mentors, Box 853, Campus Mail by December 1st @ 5pm.  If you have any questions, please call Kate or Kelsey at 626-2371.

Name:      

Date of Birth:       

Campus Address:   

Phone:   

Home Address:   

Phone:   

Email Address:   

Major:          Minor:   

Advisor:            Year:   

Organization(s) you represent:   

1.  Briefly explain your future goals and how this experience can help you in achieving those goals.

2.  List any personal experiences, strengths, training, or jobs you have had that you feel would enable you to be more effective in helping others.

Please list three references:

Name:   
Address: 
Position:  
Phone Number:  

Name:   
Address: 
Position:  
Phone Number:  

Name:   
Address: 
Position:  
Phone Number:  

National Peer Help Association:  Code of Ethics for Peer Helpers

Peer Helpers shall be people of personal integrity, as evidenced by a commitment to and pursuit of:

1.   A philosophy which upholds peer helping as an effective way to address the needs and conditions of people.

2.   Each individual’s rights to dignity, self-development and self-direction.

3.   Supervision, training and support from professional staff while involved in the peer helper program.

4.   The development of a nurturing personality which:

• Reflects a positive role model and healthy lifestyle, and

• Rejects the pursuit of personal power, elitist status and gain at the expense of others.

 5.   Maintenance of confidentiality except in the following situations which shall be reported to professional staff:

• Situations involving real or potential danger;

• Child abuse, sexual abuse;

• Severe family dysfunction, psychotic behavior, extreme alcohol and other drug abuse and other problems beyond the experience of a peer helper.

6.   Recognize personal limits- report and deal with potential threats to own emotional or physical well-being. 

Electronic Signature (type your name):    
Date:      

Click here to view and print a paper application. 
After printing the application, fill it out and bring it to the Counseling Center in the NSU Student Center 217 or mail to NSU Peer Helpers, Box 853, Campus Mail by November 22^nd @ 5pm.