Peer Counseling Application

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1 Peer Counseling Application Current Grade: Name:_ This application must be submitted to Mr. Ptomey by 4:00 pm on Thursday, April 24 th. Interview: We will be conducting interviews the week of May 5 th in the Guidance Office. Reference: You are responsible to ask someone currently teaching at Doniphan-Trumbull to recommend you for Peer Counseling. If you are a new student, see Mr. Ptomey and we will arrange for someone else to provide your recommendation. Make sure that you give your recommender the form at least one week before it is due. The teacher should give the completed recommendation to Mr. Ptomey by Thursday, April 24 th. We also may be contacting other teachers who know you. I plan on asking to recommend me for Peer Counseling. **If the space provided is not enough, please answer on a separate piece of paper.** 1. Why do you want to be a Peer Counselor? 2. What life event or person has most shaped you into the person you are right now? 3. What are some of the traits/ qualities you feel you possess that would benefit the Peer Counseling Program? What would be your greatest personal strength as a peer counselor and what would be your greatest personal weakness or limitation as a peer counselor? 4. What are some important issues you feel junior high and high school students deal with most and why? How can you help with these problems?

2 5. Peer Counselors do substance abuse prevention presentations to elementary / middle school students. Could you do this and have it honestly reflect your own personal lifestyle? 6. In your opinion, how do you relate to other people? How do you feel other people relate to you? 7. List school and community activities in which you are involved this year. Please prioritize this list as you see them (most important to least). List Peer Counseling in the priority spot you would assign to it As a peer counselor you will have to sign a contract to 1.) Work at staying chemical-free. 2.) Keep Confidentiality 3.) Meet the minimum time requirement of peer counseling meeting during MAP, 2 retreats (possibly during non school days), occasional lunch meetings, 2 to 3 presentations to elementary/middle school per semester and some evening meetings (Back to School Night and Conferences). This is the minimum requirement!

3 Contract for Peer Counseling Program ~ Doniphan-Trumbull I,, agree to maintain a high ethical standard as a Peer Counselor for the school year at Doniphan-Trumbull. ** I will: 1. Achieve a C average for the school year. 2. Have no more than 5 absences during each semester (e.g., required attendance at sporting events, music contests, state contests, etc. are exempted.) 3. Participate in the Big Brother/ Sister Program. (When established) 4. Attend the Annual Peer Counselor Retreat. 5. Participate in all the presentations to the elementary/middle schools. 6. Abide by the legal and ethical ground rules established by the Peer Counseling program as required by state and federal statutes. 7. Make a commitment to grow and change in personal ways to be a more positive and effective role model to my peers and a little brother/sister. 8. Agree to protect the other members of the program by reporting all suspected unethical breaches (e.g., confidentiality) by any member of the program. 9. Remain drug-free or commit to becoming drug-free. Your Name Parent/Guardian Signature Peer Counselor Coordinator Principal ** Failure to abide by the conditions of this contract will result in the automatic dismissal from the program.**

4 Peer Counseling ~ Faculty Recommendation Dear Teacher, Peer Counselors will serve the critical function of working with students in the middle/high school. Peer Counselors will be available in the Guidance and/or Principals Office throughout the school day to be of assistance to students. Peer Counselors are carefully chosen each spring from the upcoming sophomore, junior or senior class based on qualities of responsibility, sincerity, compassion and desire to be of help to others. They assist students with personal, social and academic needs. In the minds of many people, they will represent what Doniphan-Trumbull is all about. This candidate has selected you to provide input into the selection process. Your responses will be kept strictly confidential and will be destroyed after the selection process is complete. Please return this directly to Mr. Ptomey ~ do not give it back to the student. If at all possible, I need this form returned by April 24 th (they were instructed to give you at least a week to complete it.) Thank you! Harlan Ptomey Principal Peer Counselor: Faculty Recommender: 1. How long have you known the student? In what context (teacher, coach, etc.)? 2. Please rate the candidate on the following qualities: Qualities Excellent Good Average Poor No Basis Makes favorable impression Interpersonally Effective Sensitive & responsive to others Dependable Flexibility Able to work effectively in stressful situations Not often involved in peer conflict (Gossip, back-stabbing) Establishes quality rapport Based on your knowledge of this applicant, how successful do you think this person would be as a Peer Counselor? (circle one) UC Very Successful Average Hurt Program Unable to Comment

5 3. If you had a younger child attending Doniphan-Trumbull, how would you feel about your child adopting this person as a role model? 4. Explain why you judge this person as qualified or not qualified to be a Peer Counselor? (Please feel free to attach a more detailed description if you choose) PLEASE INCLUDE ANY OTHER COMMENTS THAT YOU CONSIDER RELEVANT TO THIS PROCESS. THANK YOU FOR YOUR INPUT!

6 What is Peer Counseling? Peer Counselors support their fellow students through stressful situations and alert a counselor in the building when difficult situations arise. They provide one-on-one support and observe confidentiality guidelines. Our goal is to make Doniphan-Trumbull a welcome environment for all students. Teachers and Students may refer students to Peer Counseling through Ms. Sjuts or Mr. Ptomey. The Program seeks dedicated, empathic and understanding applicants. Peer Counselors work within the framework of the student responsibility and rights code and Doniphan-Trumbull s educational objectives. Training objectives are also listed below. Training Objectives for Peer Counselors are as follows: 1. To develop and strengthen skills in approaching, listening, and observing. 2. To learn how to assist others in utilizing decision-making and problem solving skills. 3. To assess behavior and characteristics of students for possible referral to appropriate professionals at Doniphan-Trumbull. 4. To demonstrate responsible behavior in accordance with confidentiality. 5. To establish interpersonal relationships with fellow peer counselors. Once trained, Peer Counselors will provide mentoring (a big brother/big sister relationship between a peer counselor and one student), mediation, crisis response, and classroom presentations to elementary/middle school students on drugs/alcohol, bullying, and harassment. As a peer counseling program we are not looking for perfect people, but rather people who are honest with where they are at and show an earnest desire to become a person of integrity and high character. These students must also show a willingness to lead others by serving them. Their personal integrity in following through on their commitment to the program and to the kids with whom they work will enable us to Make a Difference, One Kid at a Time.

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