Contact Details Name * Preferred Mailing Address Home Office Home Contact Information Home Address City State Zip Office Contact Information Office Address City State Zip Preferred Telephone Number Home Office Cell Cell Phone Office Phone Home Phone Preferred Email Home/Personal Office Personal Email Work Email Please list two references, preferably, fellow LAP Volunteers or members of the Bar: Bio for CLE speaker introduction: Native City Native State Received Bachelor’s Degree from: Received Bachelor’s Degree in year: Received Law School Degree from: Received Law School Degree in year: Other Degree from: Other Degree in year: Member of the North Carolina State Bar since: Radio Buttons Solo Practitioner Member of the Firm of: Practices with: Member of the Firm of: or Practices with Professional Organizations or Other Accomplishments to be included in bio: Military service if any: Peer Counselor Data Which of the following volunteer activities are you willing and able to perform? Please check all that apply. Attend the lawyer support group in my area or the state-wide speaker meeting (via Zoom) Attend the in-person lawyer support group in my area Participate in an informal LAP intervention (where you call and/or visit a lawyer in distress) Be a liaison to a 12-step program (meet the person at meetings, introduce them, grab coffee, etc). Meet for coffee or lunch Mentoring someone Monitor someone under contract Serve on boards or committees Speak at a CLE by telling my story (in my area/local bar/district) Speak at a CLE by telling my story (but in a different area/bar/district) Speak at CLE on topics like resilience, compassion fatigue (training and materials provided) Speak at a law school (usually panels for the PR class or a wellbeing event) Sponsor someone/take them through the steps Attend law school office hours (a 2-hour time block commitment usually during lunch time) Write an article for Sidebar or the Journal to be published anonymously Podcast interview (anonymously) OtherOther Alcohol and Addiction Please select one and complete details if applicable I have been totally abstinent from the use of alcohol, and all other mood altering drugs or substances, for a continuous period immediately prior to the date this form is signed by me. I am not, nor have I ever been, chemically dependent, but I have a deep and abiding concern about alcoholism and addiction as a result of personal or professional experience. This addiction category is not applicable to me. My current sobriety date is Number of years abstinent Active member of AA Yes No Please list any other relevant 12-step program(s) in which you participate Current active member of Al-Anon Yes No Previous active member of Al-Anon Yes No Mental Health Participation as a peer counselor/volunteer on this committee is based on one having achieved a stable place of understanding of mental illness based on personal experience with mental illness in oneself or a family member or professional experience with mental illness in oneself or a family member or professional training. Please describe the nature of your personal experience and/or professional training: Many mental health conditions can be treated with medications. Describe your experience with and understanding of the pharmacological treatment of the mental conditions you are familiar with, including, if applicable, the length of time you have experienced stability through the use of medications, and the degree to which you believe any treated condition is in remission or the period for which satisfactory stability has been experienced: This mental health category is not applicable to me. This category is not applicable to me. Without identifying any individuals, please list your experience in either confronting or intervening with impaired lawyers or any experience you have with impaired family members. You may also wish to list other relevant experience, AA, Al-Anon and/or other recovery group programs, 12-step work, sponsorships, etc. Personal Bio: (Please include anything you think could be relevant in terms of trying to help another lawyer. This information will be used for internal purposes only when trying to match people with similar stories or life circumstances.) Many times LAP volunteers want refer work/clients to each other. We are creating a secure, password-protected volunteer portal where volunteers can access a searchable contact list by practice area and location. Please indicate your choice below. Volunteer Directory * Please include me. I consent to LAP including my name, phone number, email, practice area, and location (city and county) in the searchable directory available to LAP volunteers. Please omit me Confidentiality I, understand that as LAP Volunteer I may obtain confidential information about attorneys, judges, law students and others and Maintaining confidentiality is critical to the continued success of LAP in its efforts to assist impaired attorneys, judges and law students. Checkboxes * I agree that I will treat private information received in my role as a LAP volunteer in the strictest of confidence, subject to the attorney client privilege (meaning I will not share it with my spouse, my 12-step sponsor, other LAP volunteers or anyone else other than a LAP staff person) and will follow LAP policies and guidelines concerning private information. Furthermore, I understand and agree that my failure to abide by these policies may result in my immediate termination as a LAP volunteer. Electronic Signature * Date Signed and Submitted * If you are human, leave this field blank.
