Lawyer Assistance Program Volunteer Application

I hereby confirm my desire to hold appointment to membership as a peer counselor on the North Carolina State Bar’s Lawyer Assistance Program’s (LAP) Peer Volunteer Committee and my willingness to have the fact of such membership publicly disclosed by any normal and appropriate means.

It is my desire and intention to participate fully in the Committee’s peer counseling activities, including its educational and training programs, and to keep well informed on the policies and procedures established for the proper performance of the Committee’s work. I agree to attend LAP Volunteer meetings, including LAP luncheons, and other LAP events occurring in my locale.

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:

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

Please list any other relevant 12-step program(s) in which you participate

Current active member of Al-Anon

Yes

Previous active member of Al-Anon

Yes

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

LAP Volunteer Committee Application and Agreement

Contact Details

Home Contact Information

Office Contact Information

Bio for CLE speaker introduction:

Peer Counselor Data

Alcohol and Addiction

Mental Health

Confidentiality