BPD Today Advocate Application

Do not send this application via snail mail. Though this is a structured form, it does not have to be filled out exactly as it appears. Send the information in via email in any form you wish to the Director. For example you could say "My name is Maria Gonzalez and I am interested in becoming an advocate. I am 34 years old, my date of birth is ... and here is my street address...", etc.

 

Name:_______________________________    Age:_____  Date of Birth:_________

Street Address:_______________________________________________________

City:_______________________   State:__________   Zip Code:_______________

Mailing Address (if different)

Street Address:_______________________________________________________

City:_______________________   State:___________  Zip Code:_______________

County:_________________________

Phone Number: (Home)____________________  (Work)_______________________

International Address (if outside the USA):

____________________________________________________________________

____________________________________________________________________

Gender:_____  Email Address:________________________

I want to be an advocate:_____ I want to be a leader in the advocacy program:______ 
I want to be both advocate and leader:________ 

How may we contact you? (Write "Yes" in one of these options:) Phone:_____   
Email:______   Mailing Address:______

Current Psychiatric and Medical Diagnoses:__________________________________

____________________________________________________________________

____________________________________________________________________

For those with diagnoses, how long have you been stable?:_____________________

How long ago have you self injured?:_______________________________________

Additional Information: (optional) __________________________________________

_____________________________________________________________________

Signature: ________________________________             Date: _________________

Borderline Personality Disorder Today Advocate Application - 4/03
Patty Pheil M.S.W.