Bridger Questionnaire | Advocacy Unlimited

Please fill out this questionnaire to the best of your ability. The information you provide will help us to determine if our program is a good fit for you at this time. There are no wrong answers.

If you have questions of your own, please email [email protected] or call 860-505-7581.

*This form must be filled out by or with the potential participant*

*Please refrain from including sensitive or confidential material (i.e. protected health information)*

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Pronouns

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone

Email(Required)

Date of Birth

Bridger Preferences

Emergency Contact / Alternate Contact

Tell us about what is going on in your life right now.

How can we support you in facilitating change?

Is there anything else you would like to share?

Do you have a conservator? If yes, please provide contact information.

BRIDGER PROGRAM SCOPE OF ENGAGEMENT

The Bridger Program offers non-clinical, person-centered recovery support to people involved with, or at risk of involvement with, the mental health system in the State of Connecticut.

The program functions by matching participants with a Peer Bridger, who used their personal lived experiences, coupled with the principles of Intentional Peer Support and their training as Recovery Support Specialist to build authentic, safe relationships defined by mutuality, personal agency, and respect.

Toward this end, the Bridger Program requires that participants:

Are personally interested in and invested in the building of an authentic, peer-to-peer relationship
Maintain a relationship that is respectful, including maintaining proper physical and emotional boundaries.
Willing to navigate challenges through self-determination
Understand that the Bridger Program is not a clinical service provider, and has no clinical or legal power.
Understand “advocacy” as is exists within the context of the Bridger Program comes through connection, and in relation to, encouraging a participant to express their needs and required resources to their community of friends, family, service providers and colleagues.

In turn, the Bridger Program will provide:

Space and opportunity to discuss personal concerns, and offer solutions based on personal experience.
Access to a Bridger via phone and in person meetings, with a frequency determined through mutual agreement, with consideration given to the stated needs of both parties and with concern to scheduling, other obligations and availability for up to six month ( unless a documented extension is provided by the Bridger Program).
Connection to community resources
Encouragement during difficult events in participant’s lives.

The Bridger Program will not under any circumstance guarantee the following:

Vehicular transportation for participants.
Provision of cash, goods or services.
Intervene on behalf of a participant with outside entities or organizations, including but not limited to service providers, government officials, courts, attorneys and other community members

The Bridger Program reserves the right to terminate and disengage from services with participants who:

Use abusive or violent language
Repeatedly place unreasonable and inappropriate demands on Bridgers that violate stated personal and/or professional boundaries.
Engage in harassment or stalking
Unsafe or threatening behavior

Bridger Scope of Engagement - Participant Signature

By signing this document, I am stating that I understand the terms and limitations of Advocacy Unlimited’s Bridger Program, as detailed in this Bridger Program Scope of Engagement document.